Orthopedic Coding Alert

Question: A private payer has denied our claim for a level-three new patient evaluation and management (EM)  office visit for “missing/incomplete/ invalid principal diagnosis.” One of our coders says we cannot report M54.16 and M51.26 on the same claim, but I have never seen anything stating this. Who is right and how should we have coded the service?

Virginia Subscriber

Answer: Assuming the diagnosis codes you mention are correct for the E/M, your coding colleague is correct.

When a patient has a herniated or displaced disc with radiculopathy, the correct ICD-10 diagnosis code is M51.16 (Intervertebral disc disorders with radiculopathy, lumbar region). Diagnosis M51.16 is a combination code that describes both problems the patient is experiencing (displaced disc and radiculopathy). Because of this, there is no need to also report diagnosis M51.26 (Other intervertebral disc displacement, lumbar region).

When you resubmit the 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) claim, be sure to include M51.16 only; leave M54.16 (Radiculopathy, lumbar region) off the submission form.

Reminder: Payers state that you should report the code that best describes the problem; when a combination code applies (from either a diagnosis or procedure perspective), they expect you to submit it instead of multiple codes. If you report multiple diagnoses when a combination code describes all the problems, the insurer sees your claim as miscoded.