ICD-10 Coding for Lumbosacral Foraminal Stenosis(M48.062, M99.63)
Complete ICD-10-CM coding and documentation guide for Lumbosacral Foraminal Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Lumbosacral Foraminal Stenosis
M48.06-M48.07Primary Range
Spinal stenosis, lumbar region
This range includes codes for lumbar stenosis with and without neurogenic claudication, which are critical for coding lumbosacral foraminal stenosis.
Disorders of the musculoskeletal system and connective tissue, neural foraminal stenosis
This code is used for neural foraminal stenosis when it occurs as a biomechanical lesion without central 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 |
|---|---|---|---|
| M48.062 | Spinal stenosis, lumbar region with neurogenic claudication | Use when MRI confirms central stenosis with neurogenic claudication symptoms. |
|
| M99.63 | Neural foraminal stenosis | Use when foraminal stenosis occurs without central 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 lumbosacral foraminal stenosis
Essential facts and insights about Lumbosacral Foraminal Stenosis
Primary ICD-10-CM Codes for lumbosacral foraminal stenosis
Decision Criteria
clinical Criteria
- Presence of neurogenic claudication symptoms
documentation Criteria
- MRI findings of central canal stenosis
Applicable To
- Lumbar stenosis with neurogenic claudication
Excludes
- Spinal stenosis without neurogenic claudication
Clinical Validation Requirements
- MRI showing central canal stenosis with CSF obliteration
- Symptoms of neurogenic claudication such as leg pain worsened by walking
Code-Specific Risks
- Incorrectly coding without confirming neurogenic claudication can lead to audits.
Coding Notes
- Ensure documentation specifies neurogenic claudication to use this code.
M99.63 - Neural foraminal stenosis
Use when foraminal stenosis occurs without central stenosis.
Applicable To
- Foraminal stenosis as a biomechanical lesion
Excludes
- Central canal stenosis
Clinical Validation Requirements
- MRI showing nerve root compression in the neural foramen
- Absence of central canal stenosis
Coding Notes
Document specific MRI findings to support this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Neural foraminal stenosis
M99.63Differential 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 Lumbosacral Foraminal Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M48.062.
Impact
Clinical: Leads to incorrect treatment planning., Regulatory: Increases risk of audit., Financial: Potential for denied claims.
Mitigation Strategy
Educate providers on documentation requirements., Use templates with required fields.
Impact
Reimbursement: Incorrect coding can lead to reduced reimbursement., Compliance: May trigger audits due to lack of specificity., Data Quality: Impacts accuracy of clinical data records.
Mitigation Strategy
Ensure documentation clearly states the presence or absence of neurogenic claudication.
Impact
Lack of specificity in documenting neurogenic claudication.
Mitigation Strategy
Use detailed templates and checklists for documentation.
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 Lumbosacral Foraminal Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Lumbosacral Foraminal Stenosis
Use these documentation templates to ensure complete and accurate documentation for Lumbosacral Foraminal Stenosis. These templates include all required elements for proper coding and billing.
Neurology Progress Note
Specialty: NeurologyRequired Elements
- Patient's subjective symptoms
- Objective findings
- MRI results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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