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Question: I was looking through the operative notes for a patient with a spinal disc disorder, and I kept coming across the term “myelopathy.” Even though I have seen it in code descriptors, I’m not sure what it means. Could you define myelopathy, and offer any insight into how coders can spot it in the documentation?

Kansas Subscriber

Answer: The spinal cord is a group of nerves housed inside the spine that runs almost its entire length. When any part of the spinal cord becomes compressed or constricted, the resulting symptoms are known as myelopathy. 

Symptoms of myelopathy can include:

• Neck or back pain;
• Tingling, numbness, or weakness in the extremities;
• Gait disturbance;
• Hand clumsiness;
• Loss of balance; and
• Bladder or bowel issues (in rare cases). 

In the case you describe, “myelopathy” appears in the notes, so there’s no mystery. If you see notes for a patient with symptoms like those described above and you don’t see “myelopathy” mentioned, however, you might want to query the provider. Myelopathy can occur anywhere in the spine — cervical, lumbar, thoracolumbar, etc. — and most spinal disc disorder diagnosis codes that include myelopathy will also indicate anatomical location.  

Here’s a look at three myelopathy types:

• Cervical myelopathy occurs in the neck and is the most common form. 
• Thoracic myelopathy affects the middle thoracic spine, and compression in this area is typically due to bulging or herniated discs, bone spurs, or spinal trauma.
• Lumbar myelopathy of the lower spine is a rare condition because in most people, the spinal cord ends in the top section of the lumbar spine. However, if the spinal cord is low-lying or tethered, it can be affected by lumbar myelopathy.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC