EM Coding Alert
Walk Yourself Through Coding Spinal Stenosis
Hint: Patients may require multiple encounters before the provider pinpoints a Dx. A patient exhibiting signs and symptoms of spinal stenosis may visit your provider’s office numerous times and receive various diagnostic tests. Coders, therefore, need to nimbly navigate the coding process while incorporating each visit and test. Keep reading for information on how providers diagnose spinal stenosis and how coders should figure out what to report. Consider These Symptoms Signs and symptoms of spinal stenosis may include neck pain; weakness or numbness in shoulders, arms, and legs; hand clumsiness; gait imbalance disturbance; and burning or tingling involving arms or legs, explains Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, AAPC ICD-10-CM Proficient, AAPC Fellow, senior manager of healthcare consulting at Seim Johnson LLP in Omaha, Nebraska. “Practitioners most commonly diagnose spinal stenosis by taking a medical history, performing an examination and observing patient movements. They may order diagnostic testing services such as X-rays, MRI [magnetic resonance imaging] scans, or CT [computed tomography] scans to view images of the spine,” Swanson says. Look to These Codes for Diagnostic Procedures The first step in treating spinal stenosis is identifying it. Your provider will diagnose the condition with a combination of evaluation and management (E/M) services and imaging “A provider normally can anticipate stenosis in a visit, but it would normally be confirmed in an MRI or CT,” explains Lynn M. Anderanin, CPC, CPB, CPMA, CPPM, CPC-I, COSC, senior coding educator at Healthcare Information Services LLC in Park Ridge, Illinois. Here’s a sampling of some of the CPT® codes associated with E/M services, X-rays, CT scans, and MRI scans that your provider might perform or order to diagnose spinal stenosis. E/M: For the most part, your provider will initially see spinal stenosis patients in the office, which means you’ll report a code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) code set, depending on encounter specifics. X-rays: Codes from 72020 (Radiologic examination, spine, single view, specify level) through 72120 (Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views) apply to X-rays that check for spinal stenosis. The codes include, but are not limited to, the following: CT scans: Codes 72125 (Computed tomography, cervical spine; without contrast material) through 72133 (Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections) apply to CT scans that check for spinal stenosis. The codes include, but are not limited to, the following: MRI scans: Codes 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material) through 72158 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar) apply to MRI scans that check for spinal stenosis. The codes include, but are not limited to, the following: Also: Though the diagnosis might be spinal stenosis in the end, the provider might need to order X-rays, CT scans, or MRI scans on extremities to diagnose spinal stenosis — particularly if the patient complains of pain/tingling in the extremities. In such an instance, the reporting provider should select a code from 73000 (Radiologic examination; clavicle, complete) through 73723 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences), depending on encounter specifics. Look to M48.0- for Stenoses If your provider diagnoses spinal stenosis, look to these ICD-10 codes when selecting what to report: Example: An established patient with lower spine pain returns to the office after an MRI confirms lumbar spinal stenosis without neurogenic claudication. The provider spends 30 minutes in an E/M visit with the patient, including discussing the test results and treatment options. For this encounter, you’d report:
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