1 Dx being 2 different managed options

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Hello,

Any help is much appreciated!

I work for Pain Management. We deal with pts that have Lumbar Radiculopathy and Lumbar Spondylosis. From my understanding we need to use M47.26 Lumbar Other Spondylosis with Radiculopathy. My providers have stated that the pt could have 2 different managed options for this Dx. So on our office note for the pt we would have M47.26 with 2 Assessments and 2 different plans. An example would be the provider recommends a MBB for the Spondylosis. At this time for the MBB the Dx would go to M47.896 Other Spondylosis. Our Billing MAnager is worried that payors will deny once there system picks up that we haven't used M47.896 before but we used M47.26 due to pt also having radiculopathy with the understanding of the LCD shows an MBB will not be covered with pts that have radiculopathy.

Does anyone have experience with this or any thoughts?

Please help. I can not get any help on this at all.

Thanks!
 

mitchellde

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The patient's diagnosis does not change depending on the treatment, therefore the code cannot change. If the provider documents that the patient has lumbar spondylosis with radiculopathy then that is the code that must be used no matter the treatment. If the payer does not cover that diagnosis for that treatment, then the patient must be advised and offered the opportunity to sign a waiver accepting payment responsibility or decline the procedure.
 
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The patient's diagnosis does not change depending on the treatment, therefore the code cannot change. If the provider documents that the patient has lumbar spondylosis with radiculopathy then that is the code that must be used no matter the treatment. If the payer does not cover that diagnosis for that treatment, then the patient must be advised and offered the opportunity to sign a waiver accepting payment responsibility or decline the procedure.


Thank you so much for the information. My next question would be should we keep sondylosis and radiculopathy and 2 dx instead if 2 management options are different and then use 1 dx with spondylosis and radiculopathy if the same managed option?:confused:
 

mitchellde

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I am not understanding the question. You use the code that matches the provider documentation for the diagnosis. Then following coding rules and conventions, if a combined code exists you must use the combined diagnosis code. You simply cannot change the diagnosis code to match different treatment options.
 
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I am not understanding the question. You use the code that matches the provider documentation for the diagnosis. Then following coding rules and conventions, if a combined code exists you must use the combined diagnosis code. You simply cannot change the diagnosis code to match different treatment options.

Sorry for any confusion and thank you so much. I guess I am just a little confused, the 1 Dx for spondylosis and radiculopathy, my providers said that there can be 2 managed options (1 for spondylosis and a different one for radiculopathy). With that being said with ICD-10 fairly new, I didn't know if there were guidelines for the exception. Also, if my providers are using the one dx, can you count this as 2 managed options?
 
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I question this as well. Per my provider a patient can have lumbar spondylosis and Lumbar radiculopathy, two separate etiologies and areas of the lumbar spine (not the Lumbosacral spine). As a Pain Physician, they will want to treat this as epidural for the radiculopathy and a MBB for the spondylosis. Radiculopathy is not a supportive diagnosis code for a MBB. I do not feel that the combo code of M47.26 would be appropriate. I know the rules state that we should choose the most appropriate diagnosis code but how do we, as the coder, know that the combination code is really correct.
 
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