Orthopedic Coding Alert

Myelopathy, radiculopathy knowledge will make Dx choice easier.

When it comes to cervical disc disorders, there are any number of tests or surgeries that your orthopedist might perform.

“Cervical [disc] disorders could lead to many things from injections to surgery … so this is a broad subject with a lot of possible treatments,” relays Denise Paige, CPC, COSC, of PIH Health in Whittier, California.

While treatments for cervical disc disorders vary, arriving at the right diagnosis code for the condition is less ambiguous — especially for the main types of the disorder. Take a look at this rundown on diagnosis coding for the two top types of cervical disc disorders.

Spinal Cord Compression Causes Myelopathy

The first set of codes you’ll encounter is the M50.0- (Cervical disc disorder with myelopathy) code set, which concerns itself with myelopathy.

“Myelopathy are the symptoms caused by something compressing a portion of the spinal cord,” explains Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois. Keywords/phrases to look for in the notes for myelopathy include:

• pain in the neck,
• arm pain, and
• stiffness, numbness and/or weakness.

Caution: You should learn to spot the signs of myelopathy, because your provider is unlikely to spell it out. “I do not see most providers documenting the word ‘myelopathy,’ but they will document the symptoms,” relays Anderanin.

When selecting a code from the M50.0- code set, you’ll need to include a fifth character, and in some cases a fifth and sixth character, for greater specificity. So, for example, if notes indicate that the patient suffers from a cervical disc disorder at C4-C5 with myelopathy, you’ll choose M50.021 (Cervical disc disorder at C4-C5 level with myelopathy) as the diagnosis.

Note: The codes for mid-cervical disc disorders mandate a sixth character to indicate spinal level, while the codes for high or unspecified cervical regions only require five characters.

Be Careful Deciding Between Radiculopathy, Myelopathy

The next entry in the cervical disc disorder section of ICD-10 is M50.1- (Cervical disc disorder with radiculopathy). This code set addresses radiculopathy, which “pinches the spinal nerve roots and could also be caused from bone or soft tissue abnormalities,” explains Paige.

Problem: “The symptoms [for radiculopathy] are the same as myelopathy and it is often hard to determine by the documentation if it is myelopathy or radiculopathy,” explains Anderanin, but “radiculopathy involves nerve roots, while myelopathy involves the spinal cord.”

So if you’re trying to decide between myelopathy and radiculopathy, you might be able to glean enough info from the encounter notes to indicate radiculopathy. If you cannot, however, you can always contact the provider.

Code selection from the M50.1- set includes fifth — and in some cases fifth and sixth — character selection. So, for example, if notes indicate that the patient suffers from a cervical disc disorder at C5-C6 with radiculopathy, you’ll choose M50.122 (Cervical disc disorder at C5-C6 level with radiculopathy) as the diagnosis.

Note: As with the codes for myelopathy, codes for mid-cervical disc disorders for radiculopathy require a sixth character to indicate spinal level, while the codes for high or unspecified cervical regions only require five characters.