ICD-10 code M51.16 states "with radiculopathy." If the patient has intervertebral disc displacement with just lumbago and not radiculopathy there is the code selection M51.26 Other intervertebral disc displacement, lumbar region.
If the physician believes the radiculopathy is attributable to the disc displacement, then the correct code selection is M51.16. The ICD-10 code M51.16 specifically states with radiculopathy. The ICD-10 Official Guidelines for Coding and Reporting states that "signs or symptoms" that are due to a definitive diagnosis are not additionally coded. These guidelines and the code descriptor needs to be reviewed with the physician. If the patient has radiculopathy without a definitive diagnosis then radiculopathy can be coded. It there is established diagnosis such as lumbar disc displacement with associated radiculopathy then only one code is reported. You need to presented to the physician that there is an element of correct coding, that it is incorrect to select M54.16 and M51.16 if the purpose of that selection is to state the patient has disc displacement with radiculopathy.
M51.16
Intervertebral disc disorders with radiculopathy, lumbar region
M54.16
Radiculopathy, lumbar region
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/icd10cm-guidelines-2015.pdf
5. Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
18. Use of Sign/Symptom/Unspecified Codes
Use of Sign/Symptom/Unspecified Codes Sign/symptom and ?unspecified? codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient?s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn?t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate ?unspecified? code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what s known about the patient?s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.
AHA Coding Clinic 1989
Title: Excludes notes under diagnosis codes 723 and 724
Body:
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
Issue: Third
Title: Clarification - excludes notes under categories 723/724
Body:
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 inter-vertebral 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.
