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Diagnosis Codes

lcole7465

Guru
Messages
205
Location
Toledo, Ohio
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0
I have a claim for Anthem Access PPO that has denied a pain management office visit claim for "Missing/Incomplete/Invalid principal diagnosis." One of the billers is telling me that M54.16 & M51.26 cannot be billed together. I have never seen anything that these codes cannot be billed together. There is an Excludes 1 for M51.1x, but nothing for M51.2x.

Any input on this would be greatly appreciated.
 

LisaAlonso23

Expert
Messages
287
Location
Sherman, TX
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0
That is correct. When a patient has a herniated/displaced disc with radiculopathy, the correct ICD-10 code is M51.16.

M51.16 is a combination code.

Per ICD-10 Index, Gg to:

Displacement, displaced
intervertebral disc NOS
lumbar region
with neuritis, radiculitis, radiculopathy or sciatica
M51.16
 

Davieda Skobel

Networker
Messages
34
Location
Columbus Ohio
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0
I agree with Lisa.

Insurance companies expect you to use the code that best describes the problem so when you can use a combination code they expect you to use it.If you bill with two separate codes instead of the combination code they will deny it and hope you cant figure it out LOL! i always check codes in my ICD-10 Expert for Hospitals to clarify the best code. I agree that they have not clearly given instruction as to how to code the patients problem but they look at it as miss coding when there is a combination code that describes both problems in one code.

The M51.16 describes both problems the patient is experiencing.
I cant guarantee they will pay the claim with this code but you have a much better chance.
This is just my opinion but its worth a try.

These are just little tricks you learn the longer you are in billing and coding. As soon as you think you understand they change something and you start all over. Just enjoy the ride!

Good Luck
Davieda Skobel CLPN, CPC
18 years Medical Coding
31 years CLPN
Columbus Ohio
 

dwaldman

True Blue
Messages
1,600
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0
I agree with the above two responses you received. The ICD-10 CM guidelines specifically state if you have a definitive condition that includes the symptom, the symptom is not listed separately. You can also see this discussion regarding radiculopathy, neuritis, stenosis, or sciatica with disc displacement or spondylosis goes back to 1989 in AHA Coding Clinic with ICD-9. It was further clarified in 1994 by AHA Coding Clinic by stating the physician is queried and it is determined the additional condition is not attributable to the disc herniation and coded separately in that example.

https://www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf


Use of a symptom code with a definitive diagnosis code

Codes for signs and symptoms may be reported in addition to a related
definitive diagnosis when the sign or symptom is not routinely
associated with that diagnosis, such as the various signs and symptoms
associated with complex syndromes. The definitive diagnosis code
should be sequenced before the symptom code.
Signs or symptoms that are associated routinely with a disease process
should not be assigned as additional codes, unless otherwise instructed
by the classification.


c. Combination codes that include symptoms

ICD-10-CM contains a number of combination codes that identify both
the definitive diagnosis and common symptoms of that diagnosis.
When using one of these combination codes, an additional code should
not be assigned for the symptom.

__________________________
AHA Coding Clinic 1989 2nd Q, Excludes Notes Under 723 and 724





"Excludes" Notes under 723 and 724



Question: Please clarify the "Excludes" notes under 723 and 724. Do these "Excludes" notes mean that conditions due to intervertebral disc disorders or spondylosis are included in codes 721.0-722.9 or do both conditions need to be coded?



Answer: Symptoms and signs associated with (due to)spondylosis and allied disorders, 721.0-721.91, or intervertebral disc disorders (such as slipped disc or arthritic degeneration of intervertebral disc), 722.0-722.93, are included in the 721-722 code series.



Examples:

Sciatica, 724.3, due to a slipped or degenerative intervertebral disc is included in the 722 category.
Pain or neuritis due to spondylosis or intervertebral disc disorder is included in the 721-722 categories.
Spinal stenosis due to degeneration (arthritic) of the intervertebral disc is classified to the 722 category, while spinal stenosis, congenital or NOS, is classified within the 723-724 categories.

_____________________
AHA Coding Clinic 1994 3rd Q, Herniated Intervertebral Disc w Lumbar Spinal Stenosis

Clarification, Herniated Intervertebral Disc with Lumbar Spinal Stenosis



Clarification of Excludes Notes under categories 723 and 724

Question: A patient is admitted for surgical therapy because of chronic low back pain, which is presumed secondary to herniated intervertebral disc. A lumbar myelogram reveals lumbar disc herniation without myelopathy and lumbar spinal stenosis. The physician is queried and states, "The lumbar spinal stenosis is due to bony impingement." However, the physician denies the presence of spondylosis and cannot determine whether the spinal stenosis is congenital or acquired. Since the lumbar spinal stenosis is not attributable to the herniated disc, although it is an associated finding, is it appropriate to assign two codes 722.10, Displacement of lumbar intervertebral disc without myelopathy, and 724.02, Lumbar spinal stenosis?



Answer: Assign code 722.10, Displacement of lumbar intervertebral disc without myelopathy, and code 724.02, Lumbar spinal stenosis, since the physician has stated that the lumbar stenosis is not attributable to the herniated disc.



This is a clarification of the information that was previously published in Coding Clinic, Second Quarter 1989, p. 14.
 
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