Orthopedic Coding Alert

Question: A new patient presents with cervical spinal stenosis at C5-C6 and degenerative disc disease with myelopathy and radiculopathy. After a level-four evaluation and management (E/M) service, the surgeon decides to perform laminectomy on two cervical vertebrae to address the condition. There was no mention of foraminotomy or facetectomy. How should I report this encounter? Specifically, how many diagnosis codes will I need for this patient?

Tennessee Subscriber

Answer: You’ll need three diagnosis codes to successfully report this encounter. On the claim, report:

• 63001 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical) for the laminectomy
• 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.) for the E/M service
• Modifier 57 (Decision for surgery) appended to 99204 to show that the E/M led to the decision for laminectomy if the surgery is performed the same or following day as the E/M service.
• M48.02 (Spinal stenosis, cervical region) appended to 63001 and 99204 to represent the patient’s spinal stenosis
• M50.022 (Cervical disc disorder at C5-C6 level with myelopathy) appended to 63001 and 99204 to represent the patient’s myelopathy
• M50.122 (Cervical disc disorder at C5-C6 level with radiculopathy) appended to 63001 and 99204 to represent the patient’s radiculopathy

Explanation: “In this case, it is appropriate to code the cervical spinal stenosis separately,” says Jessica Miller, MHA, CPC, VP revenue cycle for Ortmann Healthcare Consulting Services. “Assign M48.02 first, as it appeared to be the primary problem treated via laminectomy. Codes M50.022 and M50.122 should be assigned as additional diagnoses.”