Neurosurgery Coding Alert

Some codes include character options for laterality and anatomy.

One of the most important parts of diagnosis coding has absolutely nothing to do with selecting ICD-10-CM codes.

Explanation: Without documentation, it is impossible for the coder to accurately choose a diagnosis code. So, if the provider comes up short on details regarding the patient’s condition — or worse, doesn’t document anything — the coder is up the creek. What could follow is miscoding the patient’s condition, or a time-consuming query to get the information just right. One of those outcomes could be costly to the patient, and the other will be costly to your practice.

Do this: Check out this primer on coding common neurological disorders, and make sure you and your providers are on the same page with every ICD-10 code choice.

Make Sure Providers Know Documentation’s Importance

If it’s not documented, it didn’t happen. These words, or variations of them, have been heard by every coder in the land.

According to guidance from Cape Fear Valley Health in North Carolina, there are certain documentation requirements that need to be met for certain neurological diagnoses to be accepted. Failure to meet these requirements could result in your patient being misdiagnosed or a refusal of services from the payer.

Note These Specifics for Alzheimer’s Patients

When a patient has Alzheimer’s disease, the provider should document whether it is early or late onset. If the patient has dementia in addition to Alzheimer’s, documentation should also include if it is with or without behavioral disturbance. “For example, combative or aggressive behavior,” Cape Fear Valley Health reports.

When a patient suffers from attention deficit hyperactivity disorder (ADHD), documentation for ADHD should include the ADHD type, such as predominantly inattentive, predominantly hyperactive, or combined type.

Once you have gathered all the documentation you need, head to the G30.- (Alzheimer’s disease) code set to choose your ICD-10-CM code.

Cognitive Issues Could Lead to Different Dx

When a patient suffers from cognitive signs and symptoms, it’s important to document just how these symptoms could be indicative of or related to another condition.

The provider should identify when signs and symptoms relate to a known mental disorder. They should also list any associated current injuries or late effects of past events. Finally, the cognitive signs and symptoms documentation should clarify the type of mental disturbance: altered mental status, age-related cognitive decline, confusion, dementia, etc.

There won’t be a single diagnosis code set for signs and symptoms; they are scattered throughout the ICD-10-CM code book.

Another diagnosis that requires extra documentation is diabetic neuropathy. For diabetic neuropathy patients, Cape Fear Valley Health recommends that the provider document specifically the type of neuropathy the patient has, if possible. These types include:

• Diabetic mononeuropathy
• Diabetic autonomic neuropathy
• Diabetic amyotrophy
• Other neurological complications

For diabetic neuropathy patients, the documentation should also include whether the patient has maintained appropriate blood glucose levels. If they haven’t, the provider should document the insulin control status as either inadequately controlled, out of control, or poorly controlled.

Dx code selection: As there are many subtypes of diabetes that depend on other diseases, complications, etc., there are diabetic neuropathy codes scattered throughout the “Diabetes mellitus (E08-E13)” code set. For type 1 and 2 patients suffering from diabetic neuropathy, look to the E10.4- (Type 1 diabetes mellitus with neurological complications) and E11.4- (Type 2 diabetes mellitus with neurological complications) code sets.

Tie Headache, Migraine to These Documentation Points

When a patient reports with a headache, you’ll want to get the provider to document the headache type first. If it is a standard headache, you’ll choose a code from the R51.- (Headache) code set.

There are, however, more specific diagnosis codes for headache syndromes, which are more severe than headaches. These headache syndromes include:

• Cluster
• Vascular
• Tension-type
• Posttraumatic
• Drug-induced

You’ll find codes for these headache types in the G44.- (Other headache syndromes) code set.

The provider should also document whether the headache is tractable or intractable, and the timing of the headache. Headache timing documentation could include terms like:

• Episodic
• Chronic
• Episodic paroxysmal hemicrania
• Chronic paroxysmal hemicrania
• Short-lasting unilateral

While migraine is a close cousin to headache, it is entirely its own condition — and it has its own documentation requirements. You’ll first need the provider to identify migraine type. Migraine types include:

• Migraine with/without aura
• Hemiplegic migraine
• Persistent migraine aura with/without cerebral infarction (CI)
• Chronic migraine

If the migraine is due to drugs, the provider should document it, along with whether the migraine was tractable/not intractable and with/without status migrainosus. If the migraine is associated with seizures or CI, the provider should note that as well.

When choosing a migraine diagnosis code, look to the very extensive and detailed G43.- (Migraine) code set.

Location Keys Myalgia Documentation

When patients suffer from myalgia, coders will need the documentation to reflect the location of the condition: the anatomical area and the laterality. Areas a patient might suffer myalgia include:

• Shoulder
• Upper arm
• Forearm
• Hand
• Fingers
• Thigh
• Ankle

But the documentation requirements don’t stop there. The provider should also indicate “when paralysis or burns accompany the calcification and ossification of muscles,” Cape Fear Valley Health reports. Further, if there are any ruptures accompanying the myalgia, they should be listed. Myalgia rupture types include:

• Nontraumatic ischemic
• Infarction
• Wasting
• Contracture of a muscle.

Though there are a few other myalgia diagnosis codes in the ICD-10-CM code book, the majority of your myalgia diagnoses will come from the M79.1- (Myalgia) code set.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC