Orthopedic Coding Alert

Question: The practitioner’s notes indicate that they treated a patient who had Horner’s syndrome. What is that, and how should I code this?

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Answer: This patient suffers from cervical sympathetic dystrophy or paralysis, which is also sometimes called Horner’s syndrome or Bernard(-Horner) syndrome.

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

Horner’s syndrome is a disorder that impacts the facial and ocular nerves, distinguished by a set of symptoms such as:

• 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 appears when the sympathetic nerve pathway, which regulates the above functions, experiences damage or interference. This condition can be triggered by a range of different 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.  

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC