ICD-9/ICD-10 Update: Know Your Regions to Choose Best Radiculopathy Diagnosis

Plus: Get ready now for expanded diagnosis choices under ICD-10.

Your physician's notes document "radiculopathy," however that doesn't send you to a definite diagnosis code. Dig deeper for the reason of the patient's problem and the affected region to make the best ICD-9 code choice.

Identify the Signs and Causes

Radiculopathy takes place when one or more spinal nerve roots become inflamed, compressed, or go through a compromised blood supply. The nerve root problem can result in pain, weakness, or numbness in the region(s) affected by the individual spinal nerve(s).

ICD-9 includes two main code choices for radiculopathy diagnoses: ICD-9 code 723.4 (Brachial neuritis or radiculitis NOS) or 724.4 (Thoracic or lumbosacral neuritis or radiculitis, unspecified).

Caution: Diagnosis ICD-9 code 724.2 (Lumbago) refers to lumbago or low back pain. Radiculopathy in the lumbosacral region of the spine can present as low back pain, so it's important to determine whether the patient has low back pain or radiculopathy.

Common reasons of low back pain involve disc degeneration, spondylosis, sprain, muscle trigger point, fibromyalgia, compression fracture, or injury.. These specific causes are different from those for radiculopathy, which is why knowing the original circumstances can help your physician diagnose -- and you select the ICD9 codes -- correctly.

Watch for the Affected Region

While reporting radiculopathy, you must concentrate and focus on the spinal region involved. The anatomical location of the patient's symptoms (cervical, thoracic, lumbar, sacral, or coccygeal) is certainly your best guide.

Reminder: The affected regions may overlap, however the nerve roots are discrete. Your physician might document nerve roots that cross from one anatomic region to another, for instance L5-S1. You'll report the lumbosacral regional involvement.

Prepare for More Detailed Choices With ICD-10

Once ICD-10 goes into effect, you'll have eight possible code choices for radiculopathy. Each incldes a specific spinal region:

• M54.11 – (Radiculopathy, occipital-atlanto-axial region)
• M54.12 -- (Radiculopathy, cervical region)
• M54.13 -- (Radiculopathy, cervicothoracic region)
• M54.14 -- (Radiculopathy, thoracic region)
• M54.15 -- (Radiculopathy, thoracolumbar region)
• M54.16 -- (Radiculopathy, lumbar region)
• M54.17 -- (Radiculopathy, lumbosacral region)
• M54.18 -- (Radiculopathy, sacral and sacrococcygeal region)

Medical Billing and Coding Tip: Having more precise diagnosis choices under ICD-10 means providers will require to be more detailed in their documentation so you can code more precisely. Even though ICD-10 won't be implemented until October 2014, now is the perfect time to start helping your providers get ready for how their documentation will change.