Neurosurgery Coding Alert

Question: My physician performed a level-three office evaluation and management (E/M) service for an established patient with cerebral palsy (CP). The notes say the patient suffers from “CP/Vogt D.” I cannot decipher this note, so which CP diagnosis code should I report?

Nevada Subscriber

Answer: Since there are at least seven different diagnosis codes that represent different CP conditions, getting the correct ICD-10-CM code for your CP patients isn’t as easy as you might think. Further, there are several synonyms for specific CP conditions that your provider might use in the notes. In fact, your provider did use one of those synonyms in this diagnosis note.

You should report G80.3 (Athetoid cerebral palsy) as the ICD-10-CM code on your claim. For your CPT^® code, you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …).

Explanation: “Vogt D” refers to Vogt disease, which is listed as a term synonymous with athetoid CP. Other conditions you might see listed that are synonymous with athetoid CP include:

• Double athetosis (syndrome);
• Dyskinetic CP; and
• Dystonic CP.