Orthopedic Coding Alert

Question: Encounter notes indicate that the orthopedist performed a level-three evaluation and management (E/M) service for a new patient who had “pinched nerve, low spine, numbness in extremities.” Final diagnosis was “lumbosac neuritis.” What is the correct ICD-10 code for this patient?

Michigan Subscriber

Answer: This sounds like lumbosacral neuritis, a type of radiculopathy. If this is indeed the case, you should report M54.17 (Radiculopathy, lumbosacral region) appended to 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) for this encounter.

However: You should go back and check the notes for more information, just to make sure you aren’t missing anything. Here’s how we arrived at M54.17 based on your encounter description:

The first clue was the note that read “pinched nerve, spine, numbness in extremities.” According to the definition listed under the M54.1- (Radiculopathy) header, “Radiculopathy is a pinched nerve in the spine causing pain, weakness, and/or numbness.”

The second clue is the final diagnosis, “lumbosac neuritis.” This is almost certainly lumbosacral neuritis, which is listed as a synonym for radiculopathy under the M54.1- header. Other terms listed as synonymous with radiculopathy under the M54.1- header are:

• Brachial neuritis or radiculitis NOS
• Lumbar neuritis or radiculitis NOS
• Lumbosacral neuritis or radiculitis NOS
• Radiculitis NOS.