Documenting Syringomyelia – A Chronic Neurological Disorder

by | Oct 15, 2020 | Resources | 0 comments

A chronic neurological disorder, syringomyelia occurs when a fluid-filled cyst (referred to as a syrinx) develops within the spinal cord. The syrinx expands and lengthens over time causing severe damage and weakness to the spinal cord. It can compress and injure the nerve fibers that transmit information to the brain and from the brain to the rest of the body. Also called hydromyelia or Morvan disease, the condition occurs due to several possible causes. However, the majority of causes are related to a condition in which the brain tissue protrudes into the spinal cord. Generally, the condition is more common in adults aged 20-40 years, but it can affect people of all age groups. Men have more chances of developing this condition than women. In some cases, people with this disorder may not experience any specific symptoms. For others, the condition causes symptoms and complications that worsens as the syrinx expands. Treatment modalities for this condition aim to relieve the pressure on the spinal cord and may depend on the severity of symptoms. Neurology medical billing and coding can be challenging for physicians treating this condition. They can partner with a reliable medical billing and coding company to streamline their medical billing process.

The exact factors that cause this neurological condition are not known. However, when the condition develops, cerebrospinal fluid (the fluid that surrounds, cushions and protects the brain and spinal cord) collects within the spinal cord itself, forming a fluid-filled cyst (syrinx). Other conditions and diseases causing the condition include – spinal cord injury/tumor, meningitis, chiari malformation (a condition in which brain tissue protrudes into your spinal canal) and other spinal cord conditions that occur at birth. In some cases, if the condition is left untreated, it can lead to severe complications like – an abnormal curve of your spine (scoliosis), chronic pain, motor difficulties (like weakness and stiffness in your leg muscles) and paralysis.

Symptoms of Syringomyelia

Symptoms associated with this condition generally develop over time. In fact, these symptoms are caused by the pressure the syrinx puts on the spinal cord and the damage that follows. Symptoms normally affect your back, shoulders, arms or legs and include –

  • Muscle weakness and wasting (atrophy)
  • Bowel and bladder function problems
  • Difficulty walking
  • Facial pain and numbness
  • Headaches
  • Loss of reflexes
  • Loss of sensitivity to pain and temperature
  • Pain in the neck, arms and back
  • Spinal curvature (scoliosis)
  • Stiffness in the back, shoulders, arms and legs

In some cases, it may take months or even years after the injury for syringomyelia to develop.

Diagnosing and Treating Syringomyelia

If a physician suspects that a person suffers from syringomyelia, he/she may be referred to a neurologist – specialized in treating the nervous system. Diagnosis of the condition may begin with a detailed medical history review and a complete physical examination wherein patients can talk to the physician about the specific signs and symptoms they are experiencing. Imaging tests like MRI scan or CT scan may be performed to identify or look for a syrinx in the spinal cord.

Treatment for this condition depends on the severity and progression of the signs and symptoms. Patients who do not experience any specific symptoms or mild symptoms may not need any treatment. In such cases, neurologists will monitor the progression of the disorder with periodic MRI and other neurological exams. On the other hand, for patients who experience severe symptoms, neurologists will recommend treatment options such as medications or surgery. Medications like gabapentin (Neurontin) may help reduce the painful sensation on the shoulders and arms that frequently occur with syringomyelia. For patients who experience worsening symptoms that interfere with their day-to-day life, surgery will be recommended. Surgery will help correct the underlying cause of the syrinx and relieve the pressure on the spinal cord. The type of surgery depends on the cause of syringomyelia. Surgical options focus on treating Chiari malformation, draining the syrinx, removing the obstruction (like a tumor or a bony growth) and correcting the spinal abnormality. All diagnostic tests and other procedures performed need to be documented using the correct medical codes. Medical billing and coding services provided by medical billing companies can help physicians use the correct codes for their medical billing process. ICD- 10 code to diagnose syringomyelia-

  • G95 Other and unspecified diseases of spinal cord
  • G95.0 Syringomyelia and syringobulbia

Patients need to have regular examinations (including periodic MRIs) as the condition can recur even after surgery. The syrinx can grow over time, requiring additional treatment. Even after successful treatment, some signs and symptoms can occur and cause permanent neurological issues. In some cases, patients may struggle with walking or have permanent weakness in their limbs.

For correct and timely billing and claims submission, healthcare practices can rely on medical billing and coding companies that provide the services of AAPC-certified coding specialists for all billing and coding tasks.

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