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Neurology & Pain Management Coding Alert

Reader Questions:

Chemodenervation Diagnosis for Stroke Patients

Published on Sun Oct 24, 2010

Question: One of our patients had a stroke years ago and now needs Botulinum toxin injections to help with becoming more ambulatory due to spasticity. I heard that we couldn't report some diagnosis codes normally used to support medical necessity for the injections because she is a stroke patient. Is this true? If so, what diagnoses might support medical necessity?Answer: The HIPAA mandated ICD-9-CM guidelines include the following directives for reporting diagnoses:"List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.""For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) [...]
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