Orthopedic Coding Alert

Surgery isn’t the first option for these patients.

An orthopedist will often confirm spinal stenosis in a patient, and then get started on treating the condition immediately. When this occurs, you will almost always defer to the more conservative means of treating the injury; surgery is typically a last resort.

The services provided to treat the stenosis will depend on the provider, of course, but you can get yourself acquainted with some of the more common conservative treatments that a provider could use for a patient with spinal stenosis.

Check out what our experts had to say about coding for spinal stenosis treatments.

Look to These Injection Codes for Stenosis Tx

According to Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, AAPC ICD-10-CM Proficient, AAPC Fellow, senior manager of healthcare consulting at Seim Johnson, LLP in Omaha, Nebraska, a PM physician might attempt to treat spinal stenosis with “medications, physical therapy, acupuncture, massage, and chiropractic treatments.”

Here’s a rundown of the more common injection-related treatments that your orthopedist might use, according to Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois:

• 0216T (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level)  through +0218T ( … third and any additional level(s) (List separately in addition to code for primary procedure).
• 62322 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance) through 62327 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)).
• 64483 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level) and +64484 (… lumbar or sacral, each additional level (List separately in addition to code for primary procedure)).
• 64493 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level) through 64495 (… third and any additional level(s) (List separately in addition to code for primary procedure)).
• 64635 (Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint) through +64636 ( … lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)).

Example: So let’s say that a patient with spinal stenosis of the lumbar region without neurogenic claudication reports to the physician for treatment; the provider performs transforaminal epidural injections with imaging guidance on two lumbar levels. For the claim, you’d report 64483 and +64484 for the injections, and M48.061 (Spinal stenosis, lumbar region without neurogenic claudication) to represent the patient’s spinal stenosis.

PT Codes Could Also Come Into Play

Your provider might also use physical therapy (PT) or rehabilitation in order to treat a patient’s spinal stenosis, Swanson says. Here’s a look at some of the code sets you could be dealing with for your provider’s PT/rehab services for these patients:

• 97161 (Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. …) through 97163 ( … A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome …)
• 97164 (Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. … )
• 97010 (Application of a modality to 1 or more areas; hot or cold packs) through 97028 (Application of a modality to 1 or more areas; ultraviolet).

Example: So let’s say that the provider treats a patient with spinal stenosis of the occipito-atlanto-axial region using unattended electrical stimulation. On the claim, you’d report 97014 (… electrical stimulation (unattended)) for the treatment and M48.01 (Spinal stenosis, occipito-atlanto-axial region) appended to represent the patient’s stenosis.

Caveat: This is just a list of some of the more conservative means that your provider might employ to treat spinal stenosis. It is not meant to be an exhaustive list, and you should check with your payer if you have any doubt about coding for your provider’s treatment services.