Differentiate Between Foraminal Stenosis and Neurogenic Claudication
Question: I have a radiology report for a multiplanar, multisequence noncontrast MRI of the lumbar spine. The radiologist’s impression is listed as “Degenerative changes of lumbar spine. Trace retrolisthesis L4-L5. Spinal canal stenosis is most severe L4-L5. Neural foraminal narrowing is most severe on left at L5-S1.” Is neural foraminal narrowing the same as neurogenic claudication? What codes should we report for this encounter? North Dakota Subscriber Answer: No, neural foraminal narrowing is not the same as neurogenic claudication. Neural foraminal narrowing (stenosis) occurs when the neural foramen gets smaller, which can place pressure on the nerves traveling out of the spinal cord. Neurogenic claudication occurs when the nerves in the lower spine become compressed, which can lead to intermittent leg pain. Assign M48.061 (Spinal stenosis, lumbar region without neurogenic claudication) to report the lumbar spine stenosis. Use M99.33 (Osseous stenosis of neural canal of lumbar region) for the neural foraminal narrowing at L5-S1. You’ll also assign 72148 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material) to report the MRI of the lumbar spine without contrast. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
