Radiology Coding Alert

Question: I am working on a chart with an impression documenting spondylosis causing spinal stenosis at L2-L3. Additionally, there is spondylolisthesis at L3-L4. The impression states radiculopathy. Should I include all four of these diagnoses?

California Subscriber

Answer: Generally, you won't be documenting symptoms when there are definitive findings in the impression. However, this rule only applies when the diagnoses in the impression cannot be further specified by incorporating the patient's symptoms. Specifically, in the case of spinal conditions, you want to be aware of indicating diagnoses of radiculopathy and myelopathy.

Take note: Beginning in October, you will also want to keep a lookout for indicating diagnoses of neurogenic claudication. A diagnosis of lumbar spinal stenosis will now require you to specify the stenosis as with or without neurogenic claudication via codes M48.061 (Spinal stenosis, lumbar region, without neurogenic claudication) and M48.062 (Spinal stenosis, lumbar region, with neurogenic claudication).

The impression in question will also need to factor in the indicating diagnosis of radiculopathy into the equation, but first you need to determine which diagnoses you should code and which you should omit. While some coders might suggest you code both spondylosis and spinal stenosis, this approach would be breaking the rule of including secondary diagnoses.

Definition: A secondary diagnosis is a condition that exists as a result of another underlying condition. In this case, the spinal stenosis is a result of the spondylosis, therefore you will not apply code M48.06 (Spinal stenosis, lumbar region). You should code both the spondylosis and the spondylolisthesis. Since you do not know whether or not the spondylolisthesis is a result of another condition, you should code it as a primary diagnosis alongside spondylosis. You will code the spondylosis as M47.26 (Other spondylosis with radiculopathy, lumbar region) and the spondylolisthesis as M43.16 (Spondylolisthesis, lumbar region).