Neurosurgery Coding Alert

Remember: You must know the sciatica’s exact location.

When it comes to reporting ICD-10-CM codes, you should double check your neurosurgeon’s medical record to make sure you caught all of the important details about the diagnosis. For example, with sciatica, you should know which side of the patient’s body was affected. If you don’t determine these details, you could risk submitting incorrect claims.

Important: “You should always report the most specific diagnostic code available,” 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. “In the following examples, you will see that a condition as simple as sciatica (i.e. leg pain) is reported based on the side of symptoms, the presence or absence of back pain, and whether the problem is from a lesion of the sciatic nerve itself.”

Read on to learn more.

Tip 1: Understand What Sciatica Symptoms Patient May Experience

If your neurosurgeon treats patients with sciatica, you should know what symptom details to look for in the medical record.

For example, a patient presents with compression of a lumbar nerve root. This patient complains of leg pain. In the medical documentation, your neurosurgeon documents tingling and numbness. He adds that the patient’s symptoms started in the patient’s lower back and then radiated through her buttocks and down the sciatic nerve in her leg.

Tip 2: Pinpoint Sciatica’s Exact Location

Since ICD-10-CM offers different codes for sciatica depending upon the body’s affected side, you must check your neurosurgeon’s medical documentation and confirm where the patient’s sciatica was located. You have these codes to look to for a sciatica diagnosis:

• M54.30 (Sciatica, unspecified side)
• M54.31 (Sciatica, right side)
• M54.32 (Sciatica, left side)

Coding example: The physician documents that the patient has sciatica on her left side. You would report M54.32 for this condition.

Tip 3: Patient Has Sciatica With Lumbago? Do This

If your neurosurgeon documents lumbago along with the patient’s sciatica, you will have different codes to choose from. When looking at these codes, you must know the side of the patient’s body affected to pick the appropriate code. You can look to the following codes for lumbago with sciatica:

• For lumbago with sciatica on the right side, you should report M54.41 (Lumbago with sciatica, right side).
• For lumbago with sciatica on the left side, you should report M54.42 (Lumbago with sciatica, left side).
• When your physician does not document which side the symptoms were present, you should report code M54.40 (Lumbago with sciatica, unspecified side).

Tip 4: Emphasize Importance of Medical Documentation

Educate your providers on the importance of documenting the patient’s condition as thoroughly as possible so you can select the most appropriate diagnosis. For example, this is an extremely important concept for sciatica and other diagnoses that depend upon laterality. If you know details such as the affected side and if other symptoms also are present (such as lumbago), then you can code more accurately.

Remember: To help your provider to remember to document these details, you can include a note of “laterality” beside the sciatica diagnosis on the superbill.

Tip 5: Don’t Forget Excludes Notes for Sciatica

When using the ICD-10-CM manual, you should always check for notes to make sure you submit your claims correctly.

For example, the sciatica category, M54.3- (Sciatica), has an Excludes1 note that tells you not to report these sciatica codes with lesion of sciatic nerve (G57.0), sciatica due to intervertebral disc disorder (M51.1-), or sciatica with lumbago (M54.4-).