DDD lumbar and Lumbar Radiculopathy

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mskinsey31

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Patient has Lumbar DDD and Lumbar Radiculopathy. Do you assume they are related or does the Documentation need to state DDD lumbar "with" radiculopathy. Do you cod as a combination code or does the documentation have to specify that one is linked to the other? Thank you,
 
Following the coding guidelines you would look in the alpha under degenerative
Degenerative
intervertebral disc NOS
with
myelopathy - see Disorder, disc, with, myelopathy
Radiculitis or radiculopathy - see Disorder, disc, with, radiculopathy
cervical, cervicothoracic - see Disorder, disc, cervical, degeneration
with
myelopathy - see Disorder, disc, cervical, with myelopathy
neuritis, radiculitis or radiculopathy - see Disorder, disc, cervical, with neuritis
lumbar region M51.36
with
myelopathy M51.06
neuritis, radiculitis, radiculopathy or sciatica M51.16
The word "with" in the listing means these conditions are assumed to be linked and would be coded together, or in this case with a combination code.
 
I have been using 2 codes m51.36 since it specifically says disc degeneration (lumbar region) and since it has nothing to do with sciatica and m54.16 for radiculopathy lumbar region..maybe I'm missing something?
:confused:
 
By following the path laid out in the index and the guideline regarding the word "with " when used in the listing, you would code to the highest level which in this instance is the one code that states which radiculopathy.
 
The documentation on the report only states that the patient has DDD-lumbar, Lumbar radiculopathy. So what I was wondering does the documentation have to state DDD-lumbar with Radiculopathy to link them because in the documentation it does not say that. or is it just assumed that because the patient has both they are related to one another?
 
Based on the coding guidelines for the meaning of the word "with" in the listing and the recent communication I received from coding clinics regarding this, the provider does not need to state the relationship when the listing is as I have indicated using the word "with".
 
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