Neurosurgery Coding Alert

Hint: If the neurosurgeon confirms a diagnosis of MS, you would report G35.

ICD-10 codes can be challenging to navigate because there are so many to choose from and specific guidelines you must follow. Although coding for multiple sclerosis (MS) may seem simple because there is only one diagnosis code, you must still make sure you follow the rules and understand which symptoms to look for.

Follow the following tips to help you report your MS claims with confidence.

Tip 1: Define MS for Clarity

Multiple sclerosis is a disease that affects the brain and spinal cord, which then leads to the loss of muscle control, vision, balance, and sensation (such as numbness). Multiple sclerosis gets its name from the buildup of fibrous tissue (sclerosis) in the brain and/or spinal cord. Scar tissue forms when myelin, the protective tissue covering the nerves, is destroyed. This process is referred to as demyelination.

When nerves aren’t covered by myelin, the signals transmitted throughout the patient’s brain and spinal cord are disrupted or stopped. Therefore, the brain is no longer able to send and receive messages effectively. Although nerves can regain myelin, the process isn’t fast enough to counter the deterioration that occurs in MS. The types and severity of symptoms and the course MS takes in a patient can vary widely, partly because of the location of scar tissue and the extent of demyelination.

Medication to look for in documentation: There is no cure for MS, but physicians can prescribe steroids and monoclonal antibodies to reduce inflammation. Additionally, immune modulators like beta interferons may help slow progression or prevent relapses. Examples of beta interferons you may see in medical documentation include Avonex^®, Rebif^®, and Betaseron®.

Physicians may also prescribe immunosuppressants, a group of drugs that inhibits the activity of the immune system, to treat advanced or chronic MS. And, physical therapy and occupational therapy may help ease patients’ symptoms, as well.

Tip 2: Discover These Symptoms Leading to Diagnosis

A MS diagnosis requires evidence of at least two areas of damage in the central nervous system (CNS) that have occurred at different times. Until the physician is able to confirm a diagnosis, you’ll code the patient’s care based on the symptoms he has exhibited.

“A common initial symptom is transient visual loss, but other symptoms may include transient weakness or numbness,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

The National Multiple Sclerosis Society’s website lists a wide range of possible symptoms. Some of the more common symptoms include the following:

• Fatigue that significantly interferes with daily life activities (R53.8-, Other malaise and fatigue)
• Walking (gait) difficulties (R26-, Abnormalities of gait and mobility)
• Numbness or tingling in the face, body, or extremities (R20.2, Paresthesia of skin)
• Muscle weakness (M62.81, Muscle weakness (generalized))
• Spasticity (R25.2, Cramp and spasm)
• Bladder dysfunction (N31.9, Neuromuscular dysfunction of bladder, unspecified)
• Dizziness and vertigo (R42, Dizziness and giddiness).

Less common symptoms of MS include the following:

• Difficulty swallowing (R13.10, Dysphagia, unspecified)
• Speech problems, including slurring (R47.1, Dysarthria and anarthria) and loss of volume (R49.0, Dysphonia)
• Seizures (R56.9, Unspecified convulsions).

Tip 3: Turn To G35 For Definite MS Diagnosis

If the neurosurgeon confirms a diagnosis of MS, then you would report G35 (Multiple sclerosis).

Don’t miss: Code G35 also includes the following conditions, according to the ICD-10 manual:

• Disseminated multiple sclerosis
• Generalized multiple sclerosis
• Multiple sclerosis NOS
• Multiple sclerosis of brain stem
• Multiple sclerosis of cord.

Coding example: The neurosurgeon diagnoses the patient with disseminated multiple sclerosis. You should report G35 for this condition, since disseminated multiple sclerosis is an included condition covered under code G35.