Wiki arthropathy

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Mlampe

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What is the code for "lumbar facet arthropathy" when there is no documentation of inflammation or arthritis in the record?
 
So if I understand this correctly, the final diagnosis is lumbar facet arthropathy. However, there is no documentation in the record to support this diagnosis. My first suggestion is to query the provider to see if additional information was obtained at the time of service but not documented. If this was the case, then your provider can complete the documentation using an addendum. However, if you can't query or the provider has nothing additional to add then I would code by signs and symptoms (such as pain, etc.).

ICD-10-CM Coding Guidelines Pg 6
Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.
 
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"Facet Joint Arthropathy" is considered to be an aspect/type of "Arthritis of the Spine," and would fall under M47: Spondylosis, which Includes "degeneration of the facet joints," which is "Facet Joint Arthropathy." Since this is designated as being in the lumbar spine, the only question then is whether there is radiculopathy or not. If not, then the code would be M47.816. If there is radiculopathy, then it would be M47.26.

I hope this helps.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
 
Spondylosis question

I have questions on the coding of lumbar or Lumbosacral Spondylosis without Radiculopathy M47.816 and M47.817.
Would you code levels for example L3-S1 as Lumbosacral only M47.817 or would you code both M47.816 and M47.817?

Secondly if you have a provider documenting Lumbar or Lumbosacral Spondylosis without Radiculopathy M47.816 or M47.817 and Lumbar Radiculopathy M54.16 would you code both?
 
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