Neurosurgery Coding Alert

Hint: Facial palsy is the same as Bell’s palsy.

Since you only have one ICD-10-CM to choose from for Bell’s palsy, you may think these claims will be easy to report; however, you must always make sure you carefully read your neurosurgeon’s medical documentation. For example, you never want to confuse a Bell’s palsy diagnosis with other facial nerve disorders, such as Melkersson’s syndrome or Geniculate ganglionitis.

Read on to learn more.

Rely on One Dx Code for Bell’s Palsy

Question 1: What ICD-10-CM codes should I report if my neurosurgeon documents a diagnosis of Bell’s palsy?

Answer: You actually only have one ICD-10-CM code for Bell’s Palsy. You should report G51.0 (Bell’s palsy).

Define Bell’s Palsy for Clarity

Question 2: What is Bell’s palsy?

Answer: Bell’s palsy is a temporary facial paralysis. In this condition, the nerves controlling the facial muscles on one side of the face become swollen or inflamed.

“The cause(s) of Bell’s palsy are not known,” 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. “There has been an association of numerous viral infectious including herpes simplex, herpes zoster, Epstein-Barr virus, among others with this condition. However, trauma and tooth extractions have also been found associated with Bell’s Palsy. Fortunately, most patients begin to improve within three weeks of onset of facial weakness and most eventually recover normal function.”

Look Out for These Symptoms

Question 3: What are the symptoms of Bell’s palsy?

Answer: The symptoms of Bell’s palsy include sudden weakness in the patient’s facial muscles. The weakness makes half of the patient’s face appear to droop, and the patient may have difficulty closing his eye on the affected side.

In most cases, the weakness is temporary and significantly improves over weeks.

Use These Terms Interchangeably

Question 4: Is facial palsy the same diagnosis as Bell’s palsy?

Answer: Yes. If you look under G51.0 in the ICD-10-CM manual, you will see that facial palsy is an included condition for this code.

Neurosurgeon Diagnoses Bell’s Palsy Like This

Question 5: How will your neurosurgeon diagnose Bell’s palsy?

Answer: Since no specific test confirms Bell’s palsy, your physician’s initial diagnosis will largely depend on observation. The patient’s history may indicate a sudden unexplained episode of unilateral facial weakness or paralysis. Some may report a headache, tearing, changes in the amount of saliva and tears, drooling, difficulty eating and drinking, change in facial appearance, impairment of taste, and hearing loss as part of the onset of Bell’s palsy. The physician would most likely obtain a complete history of current and prior injuries and illnesses.

Keep Medical Documentation Details in Mind

Question 6: My neurosurgeon performed a physical exam for a patient, and the patient ended up having Bell’s palsy. What details should I look for in the medical documentation?

Answer: During the physical exam, your neurosurgeon may note facial asymmetry, the patient’s inability to move muscles on the affected side of the face, drooling, increased distance between the top and bottom eyelids, a smooth forehead, and a flattened crease between the nose and the upper lip. Standard guidelines define that the patient should be examined for the extent of facial dysfunction, and may be graded using the House-Brackman Scale from grades I through VI, with grades I and II as having good outcomes, grades III and IV as producing moderate facial dysfunction, and grades V and VI as having poor outcomes.

Putting It All Together in an Example

The neurosurgeon performed a level-three established patient evaluation and management service. He diagnosed the patient with Bell’s palsy. You should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) and G51.0 on your claim.