Neurology & Pain Management Coding Alert

This primer shows you how to navigate the G51.0 code.

While ICD-10 only contains a single code for Bell’s palsy, the devil’s in the details.

How? When a claim for a patient diagnosed with Bell’s palsy comes, coders need to be ready to read the provider’s medical documentation carefully. Further, they need to know synonyms for Bell’s palsy so they don’t confuse it with another facial nerve disorder entirely — which could result in miscoding, affect reimbursement on claims, or reduced care effectiveness for the afflicted patient.

Keep reading to find out more about diagnosing Bell’s palsy.

Know Bell’s Palsy Dx Code

Question 1: What ICD-10-CM codes should I report if my provider documents a diagnosis of Bell’s palsy?

Answer: You actually only have one ICD-10 code for Bell’s palsy. You should report G51.0 (Bell’s palsy).

Know Bell’s Palsy Definition

Question 2: What is Bell’s palsy?

Answer: Bell’s palsy is a temporary facial paralysis. In this condition, the nerves controlling the facial muscles on one side of the face become swollen or inflamed.

“The cause(s) of Bell’s palsy are not known,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “There has been an association of numerous viral infectious including herpes simplex, herpes zoster, Epstein-Barr virus, among others with this condition. However, trauma and tooth extractions have also been found associated with Bell’s palsy. Fortunately, most patients begin to improve within three weeks of onset of facial weakness and most eventually recover normal function.”

Look Out for These Symptoms

Question 3: What are the symptoms of Bell’s palsy?

Answer: The symptoms of Bell’s palsy include sudden weakness in the patient’s facial muscles. The weakness makes half of the patient’s face appear to droop, and the patient may have difficulty closing his eye on the affected side.

In most cases, the weakness is temporary and significantly improves over weeks.

Know This Term, Too

Question 4: Is facial palsy the same diagnosis as Bell’s palsy?

Answer: Yes. If you look under G51.0 in the ICD-10 manual, you will see that facial palsy is an included condition for this code.

Understand Diagnosis Methodology

Question 5: How will your provider diagnose Bell’s palsy?

Answer: Since no specific test confirms Bell’s palsy, your physician’s initial diagnosis will largely depend on observation. The patient’s history may indicate a sudden unexplained episode of unilateral facial weakness or paralysis. Some may report a headache, tearing, changes in the amount of saliva and tears, drooling, difficulty eating and drinking, change in facial appearance, impairment of taste, and hearing loss as part of the onset of Bell’s palsy. The physician would most likely obtain a complete history of current and prior injuries and illnesses.

Scrutinize Medical Documentation Details

Question 6: My provider performed a physical exam for a patient, and the patient ended up having Bell’s palsy. What details should I look for in the medical documentation?

Answer: During the physical exam, your provider may note facial asymmetry, the patient’s inability to move muscles on the affected side of the face, drooling, increased distance between the top and bottom eyelids, a smooth forehead, and a flattened crease between the nose and the upper lip. Standard guidelines define that the patient should be examined for the extent of facial dysfunction, and may be graded using the House-Brackman Scale from grades I through VI; with grades I and II as having good outcomes, grades III and IV as producing moderate facial dysfunction, and grades V and VI as having poor outcomes.

Check Your Understanding in This Example

The provider performed a level-three established patient evaluation and management (E/M) service. He diagnosed the patient with Bell’s palsy. You should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) and G51.0 on your claim.