Neurosurgery Coding Alert

Question: Encounter notes indicate that the provider treated a patient whose final diagnosis was cervical sympathetic paralysis. How should I code this encounter?

Michigan Subscriber

Answer: This patient suffers from Horner’s syndrome, which is also known as cervical sympathetic dystrophy or paralysis.

You might also see this syndrome called Bernard(-Horner) syndrome.

On the claim, report G90.2 (Horner’s syndrome) to represent the patient’s diagnosis.

More on condition: Horner’s syndrome is a condition that affects the nerves in the face and eye. It is characterized by a combination of symptoms, including:

• Ptosis (drooping of the upper eyelid on one side)
• Miosis (constriction of the pupil on the affected side)
• Anhidrosis (decreased sweating on the affected side of the face)

Horner’s syndrome occurs when there is damage or disruption to the sympathetic nerve pathway that controls these functions. The condition can be caused by various underlying factors, such as:

• Injury or trauma to the head, neck, or chest
• Tumors or lesions in the chest, neck, or brain
• Infections, such as Lyme disease or tuberculosis
• Neurological conditions, like stroke or multiple sclerosis.