ICD-10 Coding for Cervical Stenosis of Spine(M48.02, G99.2, M54.12)
Complete ICD-10-CM coding and documentation guide for Cervical Stenosis of Spine. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Stenosis of Spine
M48.0-M48.9Primary Range
Other spondylopathies
This range includes codes for spinal stenosis, specifically M48.02 for cervical region.
Myelopathy in diseases classified elsewhere
Used when myelopathy is present due to cervical stenosis.
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 imaging confirms cervical spinal stenosis without specifying myelopathy or radiculopathy. |
|
| G99.2 | Myelopathy in diseases classified elsewhere | Use when myelopathy is present due to cervical stenosis. |
|
| M54.12 | Radiculopathy, cervical region | Use when radiculopathy is present due to cervical stenosis. |
|
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 stenosis
Essential facts and insights about Cervical Stenosis of Spine
Primary ICD-10-CM Codes for cervical stenosis of spine
Decision Criteria
clinical Criteria
- Imaging confirms cervical stenosis
documentation Criteria
- Specific cervical levels are documented
Applicable To
- Cervical spinal stenosis
Excludes
- Cervical spondylosis without myelopathy or radiculopathy (M47.812)
Clinical Validation Requirements
- MRI showing central canal stenosis <10mm
- Documentation of cervical levels affected
Code-Specific Risks
- Risk of using unspecified site code M48.00
Coding Notes
- Ensure documentation specifies cervical levels and presence of myelopathy or radiculopathy if applicable.
G99.2 - Myelopathy in diseases classified elsewhere
Use when myelopathy is present due to cervical stenosis.
Applicable To
- Myelopathy due to cervical stenosis
Clinical Validation Requirements
- MRI showing cord compression
- Clinical signs of myelopathy (e.g., hyperreflexia)
Coding Notes
Ensure clinical signs of myelopathy are documented.
M54.12 - Radiculopathy, cervical region
Use when radiculopathy is present due to cervical stenosis.
Applicable To
- Cervical radiculopathy
Clinical Validation Requirements
- EMG confirming nerve root compression
- Clinical signs of radiculopathy (e.g., dermatomal sensory loss)
Coding Notes
Ensure clinical signs of radiculopathy are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Cervical spondylosis without myelopathy or radiculopathy
M47.812Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cervical Stenosis of Spine 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 decisions., Regulatory: Increases risk of audit and non-compliance., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Always specify levels in documentation., Use templates to ensure completeness.
Impact
Reimbursement: May lead to reduced reimbursement due to lack of specificity., Compliance: Increases risk of audit due to non-specific coding., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Specify the exact cervical levels affected.
Impact
Reimbursement: Potential loss of additional reimbursement for myelopathy., Compliance: Non-compliance with coding guidelines., Data Quality: Incomplete representation of patient's condition.
Mitigation Strategy
Ensure myelopathy is documented and code G99.2 is used.
Impact
Use of unspecified codes like M48.00 increases audit risk.
Mitigation Strategy
Ensure documentation specifies cervical levels and associated conditions.
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 Stenosis of Spine, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Stenosis of Spine
Use these documentation templates to ensure complete and accurate documentation for Cervical Stenosis of Spine. These templates include all required elements for proper coding and billing.
Cervical stenosis with myelopathy and radiculopathy
Specialty: NeurologyRequired Elements
- Diagnosis
- Clinical Findings
- Imaging Results
- Treatment Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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