March 26, 2017

Documentation and Coding for Intervertebral Disc Problems

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It is estimated that 80 percent of Americans report back pain at one time or another, and treatment for such issues comes at a cost of $50 billion annually. Roughly 40 percent of those with back pain seek help from a primary care physician; another 40 percent see a chiropractor, and the remaining 20 percent find some other specialist for help. In theory, these providers should be selecting the same codes for the same conditions; however, documentation varies and the ICD-10-CM code set leaves some room for interpretation.

The conditions and diagnoses that accompany back pain vary widely. In younger adults (ages 20-60), problems with an intervertebral disc is likely to be the pain generator. In older adults (age 60+), the pain is more likely to stem from degenerative conditions such as osteoarthritis. The challenge for physicians is to make sure that they know how these conditions are organized in ICD-10-CM, and that the documentation provides the proper support.

Disorders

“Disc disorders” is a broad term used in the ICD-10-CM Tabular List to describe many problems associated with the spine. The disc disorder codes are separated into two categories: M50 for the cervical spine and M51 for the thoracic and lumbar spine. The following table (included here with permission from ChiroCode.com) includes an example for each subcategory to help providers and ancillary staff differentiate between the conditions included. For example, myelopathy involves a deficit to the spinal cord, whereas radiculopathy involves a deficit to the nerve roots. Providers should be careful to clearly distinguish the difference in their documentation. Myelopathy could include symptoms affecting the bowel and bladder, for example, and it is potentially much more serious and less common than radiculopathy, which typically only involves a single extremity.

Gwilliam Chiro 032817

The fifth character for each of these codes identifies a specific anatomic location. In 2017, sixth characters were added to some of the cervical codes to provide even more anatomic specificity. However, it should be noted that laterality is not identified by the codes even though radiculopathy is usually a unilateral condition.

Diagnostic Testing

If a provider uses a diagnosis code from these two categories, the record will likely contain diagnostic testing, such as:

• Deep tendon reflexes, muscle strength testing, and/or pinwheel testing to identify location and degree of nerve damage;
• Radiographs (X-ray), to look for bony changes that might indicate disc degeneration;
• Magnetic resonance imaging (MRI) to visualize the affected discs and nerves;
• CT scan with myelogram to visualize the affected discs and region of the cord; and
• Electro-myelogram (EMG) to measure muscle innervation deficits

If none of these tests are performed or documented, then the provider may not be able to establish certainty for the diagnosis and should consider a symptom code such as M54.5, Low back pain, and/or a code from the subcategory M54.1-, Radiculopathy, instead.

“Other”

M50.2- and M51.2- are the subcategories for “other disc displacement,” and this phrase has led to some confusion. “Displacement” is a very general term that does not distinguish between disc bulges or prolapses. However, it is notable that it does not mention nervous system involvement. Furthermore, when the ICD-10-CM code set uses the word “other,” it is essentially identifying what the condition isn’t, rather than what it is. It implies that the other codes in the category are for disc displacements as well, but this one does not fit those other descriptions. Therefore, this code might be applicable if a provider is certain, as confirmed on imaging studies, that a disc is displaced – but there is not any neurological involvement, such as with the myelopathy and radiculopathy codes.

Likewise, the M50.8- and M51.8- subcategories for “other disc disorders” suggest that none of the other codes in the category describe the type of disc problem that has been documented. Incidentally, it is very difficult to come up with an example of a disc problem that does not fit the choices available in the existing code set, so these codes may not be used very often.

Degeneration

Perhaps the most commonly used codes from these categories are M50.3- and M51.3- are for degeneration. Degeneration is a natural part of aging, and, over time, everyone will experience some changes to their intervertebral discs. For many of us, this can lead to back pain. Since degeneration involves a change in the appearance of the bone around the disc, it can often be visualized on an X-ray. As such, an X-ray report would commonly be found in the documentation when this diagnosis is used. If there are also neurological complications, then another code, such as one from the subcategory M47.2- spondylosis with radiculopathy, might be considered instead.

There are many, many more spine-related codes available in the ICD-10-CM Tabular List, but each category contains nuances and variables that providers and coders should consider as they learn to document and compare the code options. While code selection is important, documentation is ultimately king, and each diagnosis must be properly supported in order to justify reimbursement.

Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMA

Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMA, executive vice president of ChiroCode and Find-A-Code LLC, graduated from Palmer College of Chiropractic as valedictorian and is a certified professional coding instructor, medical compliance specialist, and professional medical auditor, among other things. He provides expert witness reports, medical record audits, consulting, and online courses for healthcare providers. He also writes books and articles for trade journals and is a sought-after seminar speaker. He has a bachelor’s degree in accounting and a master’s of business administration, and he is one of the few clinicians who is a certified ICD-10 Instructor and certified MACRA/MIPS healthcare professional. 

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