My Neurologist selects his own diagnosis codes and when I questioned him on using 353.2 vs 723.4 for this report conclusion he responded with 723.4 is used by chiropractors. Is his code selection correct? I seem to recall an AAPC Webinar where the presenter said Neurologists will use 353.2 in this scenario, but I don?t remember if it was correct coding.
Summary of Findings:
1. Mildly increased sensory latency difference between left median
and ulnar nerves with palmar stimulation.
2. All other nerve conduction studies are normal.
3. Needle examination shows mild chronic neurogenic changes in two
muscles innervated by the left C6 root.
Conclusions / Clinical Interpretation:
1. Abnormal EMG. The EMG is compatible with:
2. a mild, chronic (>6 months old) and non-progressive left C6
radiculopathy, and
3. a mild, left median neuropathy at the level of the wrist with
myelin changes of sensory fibers such as seen with carpal tunnel
syndrome.
4. I do not find evidence for a left C5 radiculopathy
Provider Response:
723.4 is a diagnosis used by chiropractors for any type of neck/arm pain without a substantiation of objective abnormalities.
353.2 is the diagnosis of a cervical radiculopathy per abnormalities seen on EMG. Cervical root lesion and cervical radiculopathy mean essentially the same and used when there are objective abnormalities on needle exam indicating the presence of a lesion affecting the nerves leaving the spinal cord and before becoming part of the brachial plexus.
Summary of Findings:
1. Mildly increased sensory latency difference between left median
and ulnar nerves with palmar stimulation.
2. All other nerve conduction studies are normal.
3. Needle examination shows mild chronic neurogenic changes in two
muscles innervated by the left C6 root.
Conclusions / Clinical Interpretation:
1. Abnormal EMG. The EMG is compatible with:
2. a mild, chronic (>6 months old) and non-progressive left C6
radiculopathy, and
3. a mild, left median neuropathy at the level of the wrist with
myelin changes of sensory fibers such as seen with carpal tunnel
syndrome.
4. I do not find evidence for a left C5 radiculopathy
Provider Response:
723.4 is a diagnosis used by chiropractors for any type of neck/arm pain without a substantiation of objective abnormalities.
353.2 is the diagnosis of a cervical radiculopathy per abnormalities seen on EMG. Cervical root lesion and cervical radiculopathy mean essentially the same and used when there are objective abnormalities on needle exam indicating the presence of a lesion affecting the nerves leaving the spinal cord and before becoming part of the brachial plexus.