Neurosurgery Coding Alert

Provider could use several methods to determine presence of condition.

Patients reporting for diagnosis or treatment of spinal stenosis can challenge even the most skilled coder. That’s probably because of the myriad methods there are to diagnose and treat the condition.

To avoid any spinal stenosis coding snafus, we talked to a pair of experts on diagnosing and treating the condition—and how to code for these services.

Here’s what they had to say.

Stenosis Dx Often Comes from E/M, Imaging

When your provider suspects spinal stenosis, they might be able to confirm it with an imaging test, says Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois.

“A provider normally can anticipate stenosis in an evaluation and management [E/M] visit, but it would normally be confirmed in an MRI [magnetic resonance imaging] or CT [computed tomography],” she explains.

This method of diagnosing spinal stenosis is backed up by 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.

“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 scans, CT scans to view images of the spine,” Swanson says.

Numbness? Tingling? That Could Be Stenosis

When your provider is checking if a patient has spinal stenosis, tingling in the extremities and neck discomfort lead the list of potential symptoms, according to Swanson.

“Signs/symptoms of spinal stenosis may include neck pain, weakness or numbness in shoulders, arms, legs, hand clumsiness, gait imbalance disturbance, burning or tingling involving extremity such as arms or legs,” she says.

Stenosis Tx Could Include Several Methods

“Treatment for diagnosis of spinal stenosis can include such modalities as medication, physical therapy, steroid injections and surgery,” explains Swanson. Some of the nonsurgical codes you might report for stenosis patients include:

• 62320 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance)) through 62327 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT))
• 97010 (Application of a modality to 1 or more areas; hot or cold packs) through 97028 (… ultraviolet)
• 97161 (Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.) through 97164 (Re-evaluation of physical therapy established plan of care, requiring these components: an examination including a review of history and use of standardized tests and measures is required; and revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family.).

Note: This is not a complete list of nonsurgical treatments for spinal stenosis; always code according to the specific encounter notes for each patient.

Surgical Tx Route Leads to These Codes

When more conservative treatments for spinal stenosis won’t fit the bill, your provider may recommend a surgical route. This route could take you down any number of coding avenues, says Swanson.

“Surgery could be a variety of codes including such procedures as percutaneous image guided lumbar decompression, lumbar laminectomy, cervical laminectomy, laminotomy, laminoplasty and others,” she says.

Document More Conservative Attempts Before Surgery

So let’s say your provider has diagnosed spinal stenosis, attempted to treat the condition with nonsurgical methods to no avail. They would probably turn to surgery then — but you need to remember the earlier attempts at treatment.

Why? For most payers, you’ll need to include evidence of prior, more conservative treatments the provider tried before opting for surgery. “Many insurance carriers have policies that require a time frame of conservative treatment prior to surgery,” explains Anderanin.

Swanson says that if you’re coding for Medicare payers — or payers that follow Medicare’s lead — you’ll almost certainly need to include evidence of earlier treatment.

“By statute, Medicare may only pay for items and services that are ‘“reasonable and necessary” for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,’ unless there is another statutory authorization for payment. Documentation should routinely support treatment modalities the patient has tried, response to treatment and the medical indications for surgery,” she says.