Neurosurgery Coding Alert

Report M50.8- for‘other’ cervical disc disorders.

Patients reporting to the practice with cervical disc disorders may have pain in the spinal area; the diagnosis coding for these patients can be a pain in the neck for coders, too.

How? The disorder can be represented by a number of different base ICD-10 codes. From there, coders need to concentrate on the characters in each diagnosis to ensure they are painting the most accurate picture possible of the patient’s condition.

We checked in with some experts on nailing the proper cervical disc disorder diagnosis code the first time, every time. Here’s what they had to say.

Surgeons Look to MRI, X-Ray to Confirm Disorder

In order to diagnose a suspected cervical disc disorder, the surgeon first needs to locate and identify it. The initial step in this process is typically an office/outpatient evaluation and management (E/M) service, which you’d report with 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.

After the E/M, the next step will be a service (or services) to confirm or deny the cervical disc disorder.

“Cervical disc disorders could be suspected on an X-ray, but confirmed on an MRI [magnetic resonance imaging],” explains Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois.

When coding for X-rays to look for cervical disc disorders, look to the following codes:

• 72040 (Radiologic examination, spine, cervical; 2 or 3 views)
• 72050 (… 4 or 5 views)
• 72052 (…6 or more views)

If you’re reporting an MRI related to a cervical disc disorder diagnosis, you’ll likely use one of the following codes:

• 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material)
• 72142 (… with contrast material(s))

Look to M50.0- for Myelopathy

The diagnosis codes your surgeon will use to represent the patient’s cervical disc disorder reside in the M50.- (Cervical disc disorders) code set. Within this code set, you’ll find options for several different types of disorders.

The first is a cervical disc disorder with myelopathy, which you’d report with a code from the M50.0- (Cervical disc disorder with myelopathy) code set. The codes — like all the cervical disc disorder ICD-10s — are made more specific with the 5^th character, which indicates:

• 0: unspecified cervical region
• 1: high cervical region
• 2: mid-cervical region
• 3: cervicothoracic region

“Myelopathy are the symptoms caused by something compressing a portion of the spinal cord,” explains Anderanin. In the operative report, “the keywords to look for are pain in the neck, and arm pain, stiffness, numbness, and/or weakness. I do not see most providers documenting the word ‘myelopathy,’ but they will document the symptoms.” While neck and arm pain are uncommon symptoms of myelopathy, fine hand dysfunction with loss of dexterity and gait impairment with imbalance are often seen.

Example: After a level-four office E/M for a patient with dropping of objects and trouble walking with frequent falls, the surgeon orders a three-view spinal X-ray and cervical MRI with contrast materials. The tests confirm that the patient suffers from a cervical disc disorder with myelopathy at C4-C5.

For this encounter, you’d report:

• 72142 for the MRI
• 72040 for the X-ray
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for the E/M
• M50.021 (Cervical disc disorder at C4-C5 level with myelopathy) appended to 72040, 72142, and 99214 to represent the patient’s condition

Radiculopathy Calls for M50.1-

If your surgeon confirms a cervical disc disorder with radiculopathy, you’ll report an M50.1- (Cervical disc disorder with radiculopathy) code.

Radiculopathy pinches the spinal nerve roots and could also be caused from bone or soft tissue abnormalities.

“The symptoms are the same as myelopathy and it is often hard to determine by the documentation if it is myelopathy or radiculopathy,” warns Anderanin. “Radiculopathy involves nerve roots, while myelopathy involves the spinal cord.” Neck and arm pain are much more common with radiculopathy than myelopathy.

Best bet: Keep an open line of communication with the provider in case you have questions about whether the disorder features myelopathy or radiculopathy.

Use These Codes for Displacement, Degeneration

0According to Paul Cadorette CPC, COC, CPC-P, COSC, CASCC, director of coding training and education at Nimble, “cervical disc displacement relates to a herniated disc while disc degeneration could be represented by any disease process or pathology affecting the disc leading to discogenic pain.”

Report displacement disorders with an M50.2- (Other cervical disc displacement) code.

Report degeneration disorders with an M50.3- (Other cervical disc degeneration) code.

Tag ‘Other’ Disorders With M50.8-

When your surgeon diagnoses a patient with a named disc disorder that hasn’t been assigned an ICD-10 code, opt for an M50.8- (Other cervical disc disorders) code.

According to Cadorette, a couple of conditions that fall into the M50.8- category are calcified disc and vacuum disc.

And finally, if there is no specification at all as to what type of cervical disc disorder the patient suffers from, report a M50.9- (Cervical disc disorder, unspecified) code.