Coding and Documenting Cervical and Lumbar Radiculopathy

by | Published on Aug 2, 2018 | Resources, Medical Coding News (A) | 0 comments

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Neuropathic pain is a common condition that medical billing and coding companies help pain management specialists report. Radiculopathy is a type of neuropathy that refers to a range of symptoms caused when a nerve root in the spinal column becomes pinched or damaged. Cervical radiculopathy involves pain and other symptoms caused by a compressed nerve root in the neck, while lumbar radiculopathy or sciatica is caused by problems with the nerves in the lower back.

Risk Factors for Radiculopathy

Generally, risk factors for a pinched nerve include:

  • Activities that put excessive or repetitive load on the spine, such as frequent lifting, heavy industry work, and contact sports
  • A family history of radiculopathy or other spine disorders
  • Traumatic neck and back injuries during motor vehicle collisions
  • Mechanical disorders of the cervical spine and poor posture caused by prolonged sitting and inadequate, fixed or artificial positions as in modern-day work environments

Risk factors for lumbar radiculopathy, which is somewhat more common in men, include driving occupations, back trauma, taller height, smoking, being overweight, sedentary lifestyle, history of back pain, and chronic cough.

In the younger people, cervical radiculopathy tends to be the result of disc herniation or acute injury. In the older adults, cervical radiculopathy commonly occurs due to foramen narrowing, and disc and degenerative changes in the joints.

Diagnosing Radiculopathy

Patients with a compressed nerve root present with symptoms such as sharp pain in the back, arms, legs or shoulders that may exacerbate with certain activities. Other common signs include weakness or loss of reflexes in the arms or legs and numbness of the skin and tingling sensations in the arms or legs. Sciatica is characterized by pain that radiates along the path of the sciatic nerve that branches from that lower back through the hips and buttocks and down the leg.

Pain management physicians utilize a variety of orthopedic, neurological, and imaging procedures to diagnoseradiculopathy.

  • Orthopedic tests such as SLR, WLR, Braggards, Milgram’s, Valsalva, and Soto-Hall tests can help detect sciatica
  • X-ray or CT scans may be ordered to rule out other conditions that may also be responsible for symptoms.
  • MRI can providedetailed images of soft tissue, the spinal cord, or exiting nervesin patients with chronic neck pain who have neurologic signs or symptoms. MRI can help identify the source of the nerve irritation.
  • An EMG (electromyography) test for the lower extremities can help localize the injury and also test for abnormalities in nerve signals.
  • Neurological tests for nerve-related disorders such as pinwheel, muscle strength, deep tendon reflexes, needle EMG, and nerve conduction velocity tests are used to evaluate nerve function.
  • The Bragard’s sign or Braggard’s test to evaluate whether lumbar pain originates from lumbosacral radiculopathy.
  • Straight Leg Raise (SLR) test to identify an impairment in disc pathology or nerve root irritation.

Documenting and Coding Radiculopathy in ICD-10

ICD-10 allows coding of radiculopathy with increased specificity. The radiculopathy ICD-10 codes are found in the M54.1- subcategory, part of the block M50-M54, Other Dorsopathies.

  • M54.1 Radiculopathy
  • M54.10 Radiculopathy, site unspecified
  • M54.11 Radiculopathy, occipito-atlanto-axial region
  • M54.12 Radiculopathy, cervical region
  • M54.13 Intervertebral disc disorders with radiculopathy, cervicothoracic region
  • M54.14 Intervertebral disc disorders with radiculopathy, thoracic region
  • M54.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region
  • M54.16 Intervertebral disc disorders with radiculopathy, lumbar region
  • M54.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
  • M54.18 Intervertebral disc disorders with radiculopathy, sacral and sacrococcygeal region

An ICD-10 Monitor article provides some insight into the M54.1 subcategory:

  • As laterality is not an option for these codes, the documentation should indicate the side of the body
  • As radiculopathy is a general term for spinal nerve root problems, the M54.1- subcategory includes paresthesia, hyporeflexia, motor loss, pain, neuritis (inflammation of a peripheral nerve) and radiculitis (inflammation of a spinal nerve along its path of travel). The inclusion terms for M54.1, which help identify conditions reported with the code are:
    • Brachial neuritis or radiculitis NOS
    • Lumbar neuritis or radiculitis NOS
    • Lumbosacral neuritis or radiculitis NOS
    • Thoracic neuritis or radiculitis NOS
    • Radiculitis NOS
  • There are radiculopathy combination codes that also denote the cause of the nerve irritation, such as M50.1 and M47.2. If these codes are used, there is no need to also use a code from the M54.1- subcategory. The following codes provide a more definitive diagnosis and better justify medical necessity:
    • M50.1 Cervical disc disorder with radiculopathy
    • M50.11…..occipito-atlanto-axial region
    • M50.12 …..mid-cervical region
    • M50.13 …..cervicothoracic region
    • M47.2 Other spondylosis with radiculopathy
    • M47.20 …… site unspecified
    • M47.21 …… occipito-atlanto-axial region
    • M47.22 …… cervical region
    • M47.23 …… cervicothoracic region
  • ICD-10 distinguishes between sciatica and lumbar or lumbosacral radiculopathy, with a separate code set for sciatica under M54.3.Unlike the radiculopathy codes, these codes offer right or left designations:
    • M54.31: Sciatica, right side
    • M54.32: Sciatica, left side
    • M54.41: Low back pain with sciatica, right side
    • M54.42: Low back pain with sciatica, left side

Treating Radiculopathy

The goals of treatment include: improving pain, decompressing the irritated nerve, maintaining stability and improving alignment of the spine, and protecting range of motion in the neck.

Nonsurgical treatment options for radiculopathy may include physical therapy and/or exercises, non-steroidal anti-inflammatory drugs (NSAIDs), epidural steroid injections and nerve root injections. Surgical treatments for lumbar radiculopathy involve either decompressing the nerve or stabilizing the spine. These include:

  • Anterior Lumbar Interbody Fusion (ALIF)
  • Extreme Lateral Interbody Fusion (XLIF)
  • Lumbar Laminectomy
  • Lumbar Microdiscectomy
  • Laminotomy
  • Lumbar Spinal Fusion
  • Transforaminal Lumbar Interbody Fusion (TLIF)
  • Posterior Lumbar Interbody Fusion (PLIF)
  • Cage implantation
  • Pedicle Screw
  • Deformity correction

Surgery for cervical radiculopathy involves removing pieces of bone or soft tissue, such as a herniated disc, or both. The goal of cervical spine surgery is to create more space for the nerves to exit the spinal canal. The surgical procedures commonly performed to treat cervical radiculopathy include:

  • Anterior Cervical Discectomy and Fusion (ACDF)
  • Artificial Disc Replacement (ADR)
  • Posterior Cervical Laminoforaminotomy

Using the appropriate CPT codes is necessary to report these nonsurgical and surgical services.

Medical Coding and Billing Outsourcing for Optimal Reimbursement

Understanding the related nuances and variables is necessary to report radiculopathy diagnosis accurately. With numerous spine-related ICD and CPT codes, partnering with an experienced medical billing and coding company is the best way to ensure accurate reporting of radiculopathy diagnosis and treatment for maximum reimbursement.

Outsource Strategies International.

Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

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