ICD-10 Coding for Cervical Stenosis with Radiculopathy(M48.02, M54.12)
Complete ICD-10-CM coding and documentation guide for Cervical Stenosis with Radiculopathy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Stenosis with Radiculopathy
M48.0-M54.1Primary Range
Disorders of the spine and spinal cord
This range includes codes for spinal stenosis and radiculopathy, which are directly relevant to cervical stenosis with radiculopathy.
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 the primary cause of radiculopathy without disc herniation or spondylosis. |
|
| M54.12 | Radiculopathy, cervical region | Use to specify radiculopathy when caused by 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 with radiculopathy
Essential facts and insights about Cervical Stenosis with Radiculopathy
Primary ICD-10-CM Codes for cervical stenosis with radiculopathy
Decision Criteria
clinical Criteria
- MRI confirms cervical stenosis without disc herniation.
documentation Criteria
- Documented radiculopathy symptoms and positive Spurling's test.
Applicable To
- Cervical spinal stenosis
Clinical Validation Requirements
- MRI showing cervical spinal stenosis
- Physical exam findings consistent with radiculopathy
Code-Specific Risks
- Incorrectly using this code when radiculopathy is due to a herniated disc or spondylosis.
Coding Notes
- Ensure documentation clearly links stenosis to radiculopathy.
M54.12 - Radiculopathy, cervical region
Use to specify radiculopathy when caused by cervical stenosis.
Applicable To
- Cervical radiculopathy
Excludes
- Cervicalgia (M54.2)
Clinical Validation Requirements
- Dermatomal pain/numbness
- Positive Spurling’s test
Coding Notes
Ensure radiculopathy is linked to a specific cervical level.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Myelopathy in diseases classified elsewhere
G99.2Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cervical Stenosis with Radiculopathy 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 misdiagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use specific language linking symptoms to anatomical findings.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Always document and code the underlying cause, such as M48.02 for stenosis.
Impact
Failure to document the link between stenosis and radiculopathy.
Mitigation Strategy
Ensure thorough documentation of clinical findings and imaging results.
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 with Radiculopathy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Stenosis with Radiculopathy
Use these documentation templates to ensure complete and accurate documentation for Cervical Stenosis with Radiculopathy. These templates include all required elements for proper coding and billing.
Cervical stenosis with radiculopathy diagnosis
Specialty: NeurosurgeryRequired Elements
- Patient history
- Physical exam findings
- Imaging results
- Diagnosis linking stenosis to radiculopathy
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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