ICD-10 Coding for Cauda Equina Syndrome(G83.4)
Complete ICD-10-CM coding and documentation guide for Cauda Equina Syndrome. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cauda Equina Syndrome
G83.4Primary Range
Cauda equina syndrome
This is the primary code for diagnosing cauda equina syndrome, including neurogenic bladder due to CES.
Other intervertebral disc displacement
Used when CES is caused by disc herniation, which should be coded first.
Key Information: ICD-10 code for cauda equina syndrome
Essential facts and insights about Cauda Equina Syndrome
Primary ICD-10-CM Code for cauda equina syndrome
Decision Criteria
clinical Criteria
- Presence of saddle anesthesia and urinary retention confirmed by MRI.
coding Criteria
- Sequence underlying cause before G83.4.
Applicable To
- Neurogenic bladder due to CES
Clinical Validation Requirements
- MRI findings showing compression of the cauda equina
- Symptoms such as saddle anesthesia, urinary retention, and bowel dysfunction
Code-Specific Risks
- Incorrectly coding when only 'cauda equina' is mentioned without 'syndrome'.
Coding Notes
- Ensure documentation explicitly states 'cauda equina syndrome' and includes relevant symptoms and imaging findings.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other intervertebral disc displacement, lumbar region
M51.26Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Other specified diseases of spinal cord
G95.89Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cauda Equina Syndrome to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code G83.4.
Impact
Clinical: May lead to misdiagnosis or delayed treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Use standardized templates for documentation., Ensure thorough clinical evaluation and documentation.
Impact
Reimbursement: Incorrect coding may lead to denied claims or incorrect DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure documentation specifies 'cauda equina syndrome' with symptoms.
Impact
Coding G83.4 without sufficient documentation of syndrome symptoms.
Mitigation Strategy
Implement regular coding audits and training.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Cauda Equina Syndrome, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cauda Equina Syndrome
Use these documentation templates to ensure complete and accurate documentation for Cauda Equina Syndrome. These templates include all required elements for proper coding and billing.
Neurosurgery evaluation for suspected CES
Specialty: NeurosurgeryRequired Elements
- Neurological examination findings
- Imaging results
- Symptom documentation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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