Neurosurgery Coding Alert

Question: The surgeon consulted a patient two-weeks following a cervical laminectomy for spinal stenosis. The patient complained of severe pain at the area previously operated on. There is concern by the surgeon that the patient may be experiencing post-laminectomy syndrome. What ICD-10 codes should we use in this case?

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Answer: In this case, you've got three diagnoses to consider, one of which being a definitive complication symptom from the surgical procedure. First of all, don't make the false assumption that you should code this visit with the primary diagnosis of M48.02 (Spinal stenosis, cervical region) since that's the basis behind the procedure. Instead, check out these ICD-10 guidelines on coding complications from surgery.

According to Section II, Part G in the ICD-10-CM, "When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 104 of 117 specificity in describing the complication, an additional code for the specific complication should be assigned."

You can now conclude that you should not code M48.02 as the principal diagnosis. In fact, since the patient has technically already been treated for the stenosis, it's not applicable as a diagnosis at all in this case. Instead, you've got to determine the correct surgical complication code for postoperative cervical spine pain. Since surgical complication codes tend to lack specificity in respect to anatomical sites, the most accurate code available is G89.18 (Other acute postprocedural pain).

Caution: "The surgeon's speculation that the patient is experiencing post-laminectomy syndrome is not enough to warrant a diagnosis code," explains Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. "However, if the surgeon definitively concluded that the patient was suffering from post-laminectomy syndrome, you would exclusively apply code M96.1 (Postlaminectomy syndrome, not elsewhere classified) without the need for G89.18," she adds.