spondylosis code

[jeskla]

Hi,
I think I'm reading too much into this, but please help me if you can. In the example below, the patient comes in for back pain to see our pain management doctor for pain control. I'm wondering whether to use M47.816 or M47.26 for the lumbar spondylosis that is mentioned in the MRI section.

X-Ray Data: MRI of the lumbar spine was reviewed with the patient. Notably Mr. ______ has lower lumbar spondylosis with an L4-left central and subarticular disk protrusion traversing on his left L5 nerve root. He also has an L4-L5 disk bulge with right central and subarticular disk protrusion impinging on the traversing right S1 nerve root.

Assessment:
1. Other chronic pain. -g89.29
2. Mechanical low back pain- not coded
3. L4-L5 degenerative disk disease and disk displacement with right greater than left lumbar radiculopathy. M51.16

I'm wondering if I should use M47.816 (spondylosis without radiculopathy) or M47.26 (with radiculopathy) for the lumbar spondylosis that is mentioned in the MRI section above. Since the assessment portion only has radiculopathy linked to the disc, should I just go with M47.816? Or do I use M47.26 because of the presence of radiculopathy.

Thank you,
J

 

[AlanPechacek]

First of all, I would recommend that you restrict your codes to those of your Pain Management Specialist from his Clinical Assessment/Diagnoses, and not put in or code the Radiology Report contents (i.e. the diagnosis/term "Spondylosis"). You are coding for him, not the Radiologist. Your physician does not mention Spondylosis in his Assessment.
The G89.29 code is necessary to indicate that your physician is evaluating and treating the patient for pain, not the cause of the pain.
"Mechanical" low back pain does not have a specific ICD-10 code, but would fall under the Dorsalgia Code Set (M54), in particular Low Back Pain (Lumbago NOS): M54.5. But, this code Excludes1 M51.26: "lumbago" due to intervertebral disc displacement. So you are correct in not coding this since the patient's pain is the result of pathology at the L4-5 disc, which is more specific for this patient.
As for his third "diagnosis," he actually gives three diagnoses: "degenerative disc disease;" "disc displacement;" (both at L4-5); and "with radiculopathy." For what it is worth, the "displaced" disc (M51.26) is the result or consequence of the "degenerated" disc (M51.36), but it is actually the presence of "radiculopathy" that determines the final code, which is M51.16: Lumbar Intervertebral Disc Disorder with Radiculopathy. Neither M51.2_ nor M51.3_ include "with radiculopathy" in the code description, so these would not be included in the code list even though they are of some clinical significance in a broader sense as to what was causing in the radiculopathy. Some people might argue that all could/should be listed.

Hopefully this helps you.

Respectfully submitted, Alan Pechacek, M.D.

 

[jeskla]

Thank you Dr. Pechacek. I appreciate your wisdom and response.