Neurosurgery Coding Alert

Myelopathy, radiculopathy among conditions that can accompany primary issue.

When a patient suffers from a cervical spinal disc disorder, coders must be on the lookout for the most accurate diagnosis code possible, taking into account the specific anatomical area and any secondary conditions that might accompany the primary disorder. Without this information, you risk miscoding the condition, which could affect patient care and your practice’s reimbursement.

Help’s here: During her “Spine and Stimulator Coding” presentation at HEALTHCON 2021 Dallas, Jessica Miller, MHA, CPC, VP revenue cycle at Ortmann Healthcare Consulting Services in South Carolina, showed coders the ins and outs of choosing the most accurate diagnosis codes for your spinal disc disorder patients.

Here’s what she had to say.

Combine Codes When Possible

When reporting ICD-10 codes for cervical spinal disc disorder, Miller stressed that perseverance and consistency are necessary traits when coding cervical disc disorders, as details you need are often buried in the notes — or not on the operative report at all. This means that you might have to go back and forth with the provider to find the most accurate diagnosis code. Also, be prepared to look at the encounter notes more than once when choosing these ICD-10s, Miller said.

“You’ve got to be scrubbing that note, to see what your doctor’s specifically saying so you can get to the right code,” she said.

Miller offered several tips. “If multiple levels of the cervical spine are affected, you can only report, the highest level,” explained Miller. For example, if a patient has a disc disorder at C4-C5 and C5-6, you should code to C4-5.

Codes can be combined for radiculopathy and disc disorder. For example, you can report:

• Cervical disc herniation at C5-6 with radiculopathy as M50.122 (Cervical disc disorder at C5-C6 level with radiculopathy).
• Cervical disc herniation at C4-5 and C5-6 with radiculopathy and stenosis as M50.121 (Cervical disc disorder at C4-C5 level with radiculopathy) and M48.02 (Spinal stenosis, cervical region).

The same rules apply to diagnosis coding for patients with myelopathy and disc disorders, explained Miller.

Check out These Examples

To demonstrate best practices for diagnosis coding for patients with spinal disc disorder, Miller walked attendees through several scenarios that featured patients with conditions you could see at your practice. (All examples are from 2018 AHA Coding Clinic, per Miller.)

Example 1: A patient presents with cervical spinal stenosis C5-C6 and degenerative disc disease with myelopathy and radiculopathy that is surgically treated via laminectomy. What ICD-10 code(s) would you choose for C5-C6 cervical spinal stenosis and degenerative disc disease with myelopathy and radiculopathy?

Answer 1: In this case it is appropriate to code the cervical spinal stenosis separately, explained Miller. You would report the following diagnosis codes:

• M48.02 as the primary diagnosis to represent the primary problem treated via laminectomy.
• M50.022 (Cervical disc disorder at C5-C6 level with myelopathy) for the myelopathy.
• M50.122 (Cervical disc disorder at C5-C6 level with radiculopathy) for the radiculopathy.

Example 2: What is the code assignment for stenosis of the cervical spine at C3-C6 with myelopathy?