ICD-10 Coding for Cervical Foraminal Stenosis(M48.02, M99.21)
Complete ICD-10-CM coding and documentation guide for Cervical Foraminal Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Foraminal Stenosis
M48.0-M48.03Primary Range
Spinal stenosis, including cervical region
This range includes codes for spinal stenosis in various regions, with M48.02 specifically for the cervical region.
Biomechanical lesions, including subluxation and osseous stenosis
These codes are used to specify the etiology of the stenosis, such as subluxation or osseous causes.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M48.02 | Spinal stenosis, cervical region | Use when cervical stenosis is identified without a specific cause or when it is the primary diagnosis. |
|
| M99.21 | Subluxation stenosis | Use when stenosis is caused by subluxation, confirmed by imaging. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for cervical foraminal stenosis
Essential facts and insights about Cervical Foraminal Stenosis
Primary ICD-10-CM Codes for cervical foraminal stenosis
Decision Criteria
clinical Criteria
- Presence of cervical stenosis on imaging with correlating symptoms.
documentation Criteria
- Detailed documentation of vertebral levels and symptoms.
Applicable To
- Cervical spinal stenosis without specific etiology
Excludes
- Cervical myelopathy (G95.0)
Clinical Validation Requirements
- MRI or CT showing stenosis at C2-C6 levels
- Clinical symptoms correlating with imaging findings
Code-Specific Risks
- Risk of under-documenting the etiology, leading to incomplete coding.
Coding Notes
- Ensure documentation specifies the vertebral level and etiology if known.
M99.21 - Subluxation stenosis
Use when stenosis is caused by subluxation, confirmed by imaging.
Applicable To
- Stenosis due to vertebral subluxation
Excludes
- Non-subluxation related stenosis
Clinical Validation Requirements
- Dynamic X-rays showing subluxation
- Clinical correlation with symptoms
Coding Notes
Document the cause and confirm with imaging.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cervical Foraminal Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M48.02.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Use templates that prompt for specific levels., Regular training on documentation standards.
Impact
Reimbursement: May lead to lower reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data for clinical and research purposes.
Mitigation Strategy
Add ancillary codes like M99.31 or M99.51 to specify the etiology.
Impact
Lack of specific details on stenosis etiology and levels.
Mitigation Strategy
Implement thorough documentation practices and regular audits.
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 Cervical Foraminal Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Foraminal Stenosis
Use these documentation templates to ensure complete and accurate documentation for Cervical Foraminal Stenosis. These templates include all required elements for proper coding and billing.
Cervical stenosis with radiculopathy
Specialty: NeurosurgeryRequired Elements
- Exact vertebral levels affected
- Etiology of stenosis
- Symptoms correlating with imaging
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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