Wiki Question regarding the individual use of levels dx codes for pain management

[jennburgel]

I was wondering if it makes a difference if a dx for a pain injection ie: Lumbar radiculopathy which is stated on the pre op and post op dx of the op note, however within the body of th note it says they injected l5-s1. Wouldn't you code to th specificity of the level m54.17. I am seeing it coded as m54.16 which is lumbar region. When i asked i was informed that it is coded off of the pre op, post op description not the body of the note. My question is two fold. Why is there an actual icd10 for each region if its not being used and for auditing can this hurt us? I welcome any educated reponses. Thanks

 

[Melissa Harris CPC]

I am sorry I just saw this. It is important that the procedure level match the ICD-10 code. So if it is L5-S1 make sure you use the lumbosacral diagnosis code. I would think it would come back if there was an audit.


Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management

 

[sonyablair]

In this scenario what dx code/codes would be used for multiple levels - L4-L5 and L5-S1 for example. I normally see only one dx code reported (ie M54.16 or M54.17).