Neurosurgery Coding Alert

ICD-10 offers a simple single and specific code for this condition.

Bell’s palsy is one diagnosis that will never throw challenges in reporting. ICD-10 offers a simple and precise code for this diagnosis. All you need to make sure is that you have confirmed the signs and diagnosis of Bell’s palsy in the clinical documentation.

What is Bell’s palsy? Bell’s palsy is a temporary facial paralysis. In this condition, the nerves controlling the facial muscles on one side of the face become swollen or inflamed. As a result of this condition, half of the patient’s face droops and one has difficulty closing one’s eye on that side.

Diagnosis of Bell’s palsy: Since no specific test confirms Bell’s palsy, your physician’s initial diagnosis will largely depend on observation. The patient’s history may indicate a sudden unexplained episode of unilateral facial weakness or paralysis. Some may report a headache, tearing, changes in the amount of saliva and tears, drooling, difficulty eating and drinking, change in facial appearance, impairment of taste, and hearing loss as part of the onset of Bell’s palsy. The physician would most likely obtain a complete history of current and prior injuries and illnesses.

What to expect in physical exam documentation: In the physical exam, the physician may note facial asymmetry, the patient’s inability to move muscles on the affected side of the face, drooling, increased distance between the top and bottom eyelids, a smooth forehead, and a flattened crease between the nose and the upper lip. Standard guidelines define that the patient should be examined for the extent of facial dysfunction, and may be graded using the House-Brackman Scale from grades I through VI, with grades I and II as having good outcomes, grades III and IV as producing moderate facial dysfunction, and grades V and VI as having poor outcomes.

ICD-10 code: ICD-10 offers you a single specific code for Bell’s palsy, G51.0 (Bell’s palsy). This makes your reporting precise and complete.  “This was formerly reported with ICD-9 351.0,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Do not miss electroneurography: Physicians might perform electroneurography (ENoG) of the facial nerve primarily to diagnose Bell’s palsy and/or other facial paralysis disorders. You would report 92516 (Facial nerve function studies [e.g., electroneuronography]) when your physician performs this procedure.