Neurosurgery Coding Alert

Question: The provider performed a level-four office evaluation and management (E/M) service for a patient that suffered from “discitis.” That’s all I have; no mention of type, anatomical location, etc. What should I do?

Montana Subscriber

Answer: The ideal course of action would be to contact the performing provider and ask them for the information you need regarding the discitis diagnosis. That isn’t always possible, however. 

So, if you cannot get the info you need from the provider, report M46.40 (Discitis, unspecified, site unspecified) to 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) on your claim. That’s about as specific as you can get with this wafer-thin encounter note.

1 more option: You might be able to uncover at least the anatomical location of the discitis via the encounter notes. That would make the diagnosis more specific, if not dead-on.

If you do figure out the anatomical location of the discitis — but not the type — choose from the following codes:

• M46.40 (Discitis, unspecified, site unspecified)
• M46.41 (… occipito-atlanto-axial region)
• M46.42 (… cervical region)
• M46.43 (… cervicothoracic region)
• M46.44 (…thoracic region)
• M46.45 (… thoracolumbar region)
• M46.46 (… lumbar region)
• M46.47 (… lumbosacral region)
• M46.48 (… sacral and sacrococcygeal region)
• M46.49 (Discitis, unspecified, multiple sites in spine).