Diagnosing, Documenting, and Coding for Radiculopathy

June 30th, 2017 - Evan Gwilliam, DC, MBA, BS, CPC, CCPC, CPC-I, CPMA, NCICS, MCS-P, QCC, CMHP
Categories:   Chiropractic   Documentation Guidelines   Coding  
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Radiculopathy can be an unpleasant condition, but diagnosing, documenting and coding for it does not have to be. It just takes a little research. The brain communicates with the body via the spinal cord which is protected by the bones of the spinal column, called vertebrae. Nerve roots exit in between each bone through openings called foramen. The nerves from the neck carry signals back and forth to and from the arms, hands, and fingers. Cervical radiculopathy is the name or pain and other symptoms caused by problems with these nerves. Problems with the nerves from the low back can cause leg and feet symptoms, called lumbar radiculopathy or sometimes sciatica.

Diagnosing radiculopathy can be done with a variety of orthopedic, neurological, and imaging procedures. Orthopedic tests reproduce the symptoms by increasing pressure or stress on the affected nerves. You might see documentation with names like "Straight Leg Raiser,” "Braggard's,” "Lasegue's," and "Bechterew's."

Common neurological tests for nerve-related disorders include pinwheel, muscle strength, deep tendon reflexes, needle EMG, and nerve conduction velocity (NCV) tests. These tests identify if the nerves are functioning properly. In many cases diagnostic imaging is also helpful to identify the source of the nerve irritation, such as a herniated intervertebral disc, so an MRI report might be found in the record. A medical record with a diagnosis or radiculopathy would be expected to include at least some of these tests.

If M54.17 Lumbosacral radiculopathy is reported, the following is an example of typical documentation that would support it:

Subjective: Patient is a 55 year old male who has worked on the docks, engaged in heavy labor, for 25 years. He reports numbness and shooting pain from the right buttock to the right posterior thigh and lateral ankle/foot which increases with sneezing or coughing.

Objective: Decreased sensation via pinwheel testing along right S1 dermatome. Lasegue's test reproduces the symptoms. Ankle plantar flexion and eversion is 4 out of 5 on the right. Achilles reflex is absent on the right.

Radiculopathy codes in ICD-10 are found in the M54.1 subcategory, part of the block M50-M54 Other Dorsopathies, within Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue (M00-M99). There are nine code choices, with the fifth and final character designating the spinal region associated with the radiculopathy. Interestingly, laterality is not an option for these codes, though the side of the body should still be documented. There are five inclusion terms, which are a listing of synonyms or additional conditions assigned to that code.

They include the following:

Brachial neuritis or radiculitis NOS

Lumbar neuritis or radiculitis NOS

Lumbosacral neuritis or radiculitis NOS

Thoracic neuritis or radiculitis NOS

Radiculitis NOS

Some providers may prefer to distinguish between these conditions, and, in fact, one of the reasons for the transition to ICD-10 was increased specificity. In this case clinicians do not have that option. Though definitions vary, radiculopathy is a general term for the condition of spinal nerve root problems, including paresthesia, hyporeflexia, motor loss, and pain. Neuritis is inflammation of a peripheral nerve and radiculitis is defined as inflammation of a spinal nerve along its path of travel, such as dermatome. The M54.1 - subcategory includes them all. Documentation of any one of these inclusion terms would be reported with these codes.

It is also important to note that other diagnosis codes, such as M50.1 - Cervical disc disorder with radiculopathy or M47.2 - Other spondylosis with radiculopathy are radiculopathy combination codes that also explain the cause of the nerve irritation. In these cases, it would not be necessary to also use a code from the M54.1 - subcategory. In fact, these codes are preferred because they provide a more definitive diagnosis, and therefore better justify medical necessity.

Some courses consider the term sciatica to be synonymous with lumbar or lumbosacral radiculopathy, but the codes do offer right or left designations, while the radiculopathy codes do not. It may help to differentiate sciatica by defining it as numbness, tingling, weakness, and leg pain that originates in the buttock and travels down the path of the sciatic nerve in the back of the leg. However, radiculopathy will follow the path of the nerve root as it exits the spinal column. This pattern often wraps around the leg rather than following the sciatic nerve down the posterior of the leg.

Diagnosing, documenting and coding for radiculopathy may seem complex. However, a thorough understanding of the condition and coding options will make it simple for a provider who does a little homework.

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