ICD-10 Coding for Lumbar Spondylosis without Myelopathy or Radiculopathy(M47.816)
Complete ICD-10-CM coding and documentation guide for Lumbar Spondylosis without Myelopathy or Radiculopathy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Lumbar Spondylosis without Myelopathy or Radiculopathy
M47.2-M47.9Primary Range
Other spondylosis
This range includes codes for spondylosis affecting various regions of the spine, including the lumbar region without myelopathy or radiculopathy.
Key Information: What is ICD-10 code M47.816?
Essential facts and insights about Lumbar Spondylosis without Myelopathy or Radiculopathy
Primary ICD-10-CM Code for m47816
Decision Criteria
documentation Criteria
- Documentation must explicitly state 'without myelopathy or radiculopathy'.
clinical Criteria
- Imaging shows degeneration without nerve compression.
Applicable To
- Degenerative disc disease of the lumbar spine without nerve involvement
Clinical Validation Requirements
- Imaging studies showing degeneration without nerve compression
- Clinical examination confirming absence of neurological symptoms
Code-Specific Risks
- Incorrect use without explicit documentation of absence of myelopathy/radiculopathy
Coding Notes
- Ensure documentation explicitly states 'without myelopathy or radiculopathy' to use M47.816.
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.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Lumbar Spondylosis without Myelopathy or Radiculopathy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M47.816.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Increases risk of audit and non-compliance., Financial: Potential for denied claims and revenue loss.
Mitigation Strategy
Educate providers on documentation standards, Use templates with required elements
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines may result in audits., Data Quality: Inaccurate data entry affects patient records and statistics.
Mitigation Strategy
Ensure documentation explicitly states absence of myelopathy/radiculopathy.
Impact
Failure to document absence of myelopathy/radiculopathy can trigger audits.
Mitigation Strategy
Ensure thorough documentation and regular training for providers.
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 Lumbar Spondylosis without Myelopathy or Radiculopathy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Lumbar Spondylosis without Myelopathy or Radiculopathy
Use these documentation templates to ensure complete and accurate documentation for Lumbar Spondylosis without Myelopathy or Radiculopathy. These templates include all required elements for proper coding and billing.
Chronic lumbar spondylosis evaluation
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Exclusion of neurological symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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