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An Overview of Spinal Stenosis and How to Report It Using ICD- 10 Codes

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Spinal stenosis is a condition that causes abnormal narrowing in the spinal canal resulting in low back pain as well as pain in the legs. The right ICD-10 codes have to be used for reporting this procedure on medical claims.

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An Overview of Spinal Stenosis and How to Report It Using ICD- 10 Codes

  1. 1. www.outsourcestrategies.com 1-800-670-2809 An Overview of SPINAL STENOSIS and Reporting It Using ICD- 10 Codes The right ICD-10 codes have to be used for reporting Spinal stenosis procedure on medical claims. 8596 E. 101st Street, Suite H Tulsa, OK 74133 (800) 670 2809 outsourcestrategies.com 2018 OUTSOURCE STRATEGIES INTERNATIONAL
  2. 2. www.outsourcestrategies.com 1-800-670-2809 Spinal stenosis is a condition that causes abnormal narrowing in the spinal canal, which limits the amount of space available for the spinal cord and nerves. As spinal stenosis becomes more severe, there is compression or squeezing of the spinal cord and its nerves. This spinal condition can occur anywhere in the spinal canal, but it is most common in the cervical and lumbar spine. One of the most common reasons to develop spinal stenosis is degenerative arthritis or bony and soft tissue changes that result from ageing. The condition is most commonly seen in patients above the age of 50 years and becomes progressively more severe with increased age. However, not everyone develops spinal stenosis as they become older. People who have a family history of spinal stenosis or other spinal or back problems are at an increased risk of developing this condition due to this genetic trait. Also, heavy laborers or athletes (who regularly expose their lower back to a great extent) are at an increased risk to develop spinal stenosis. It may also occur in people with certain connective tissue diseases such as ankylosing spondylitis. Quick and effective diagnosis of the root causes and symptoms of spinal stenosis is important for healthcare providers to provide proper treatment. Accurate documentation is crucial to ensure appropriate care and medical coding outsourcing is an ideal option for physicians to streamline their documentation process. What Are the Common Symptoms of Spinal Stenosis? Spinal stenosis is most commonly caused by wear-and-tear changes in the spine related to osteoarthritis. Some of the other causes of this spinal disorder may include herniated disks, thickened ligaments, overgrowth of bone, tumors, and spinal injuries. In severe cases of spinal stenosis, physicians may recommend surgery to create additional space for the spinal cord or nerves. The symptoms of this condition may depend on where the
  3. 3. www.outsourcestrategies.com 1-800-670-2809 stenosis occurs in the spinal column and it can vary from patient to patient, ranging in severity from minor to crippling. The location and severity of the condition may determine the type of symptoms you may experience. In some cases, people with spinal stenosis may not experience any specific symptoms. Others may experience some common symptoms which may include – • Neck pain • Pain, numbness, tingling, or cramping in the arms, foot or leg • Weakness in a hand, arm, foot or leg • Problems with walking and balance • Tingling, numbness, or pain that radiates from the lower back into the buttocks and legs • Hot or cold feelings in the legs • Lower back pain while standing or walking • Weakness along the path of the nerve being compressed • Bowel or bladder dysfunction (urinary urgency and incontinence, in severe cases) How Is Spinal Stenosis Diagnosed and Documented? For those experiencing symptoms of spinal stenosis, physicians will begin the diagnosis by enquiring about the initial signs and symptoms, evaluating previous medical history, performing a detailed physical examination and observing patient body movements. Physicians may conduct several diagnostic imaging tests to confirm a suspected diagnosis of this spinal disorder. These diagnostic imaging tests include – • X-ray, MRI scan or CT scan to view images of the spine • Electromyelogram to check the health of spinal nerves • Bone scans to look for damage or growths in the spine
  4. 4. www.outsourcestrategies.com 1-800-670-2809 Treatment for this spinal condition mainly focuses on understanding the risk factors, reducing symptoms and relieving severe pain. The first-line treatment will begin non-surgical modalities such as physical therapy exercises, epidural steroid injections, electrical nerve stimulation and non- steroidal anti-inflammatory medications. In most cases, it can be treated without surgery. Physicians who provide specialized treatment to the patients are reimbursed for their services. Accurately diagnosing the condition and submitting proper clinical documentation helps in promoting error-free billing practices. A professional medical coding company can help physicians with their medical billing tasks. ICD-10 codes for diagnosing spinal stenosis include – M48.0 - Spinal stenosis • M48.00 - Spinal stenosis, site unspecified • M48.01 - Spinal stenosis, occipito-atlanto-axial region • M48.02 - Spinal stenosis, cervical region • M48.03 - Spinal stenosis, cervicothoracic region • M48.04 - Spinal stenosis, thoracic region • M48.05 - Spinal stenosis, thoracolumbar region M48.06 - Spinal stenosis, lumbar region • M48.061 - Spinal stenosis, lumbar region, without neurogenic claudication • M48.062 Spinal stenosis, lumbar region, with neurogenic claudication • M48.07 Spinal stenosis, lumbar region, lumbosacral region • M48.08 Spinal stenosis, lumbar region, sacral and sacrococcygeal region
  5. 5. www.outsourcestrategies.com 1-800-670-2809 Spinal stenosis can lead to gradual but steady loss of strength in the legs. The severe pain caused by this condition can be quite disabling and affect your day-to-day life. However, there is no cure for this condition as it most commonly occurs due to degenerative arthritis that occurs with regular ageing. However, you can take several important steps to help limit the severity of symptoms. Maintaining a healthy body weight and doing regular exercises (flexing, stretching and strengthening exercises) could help in this regard. Patients should try to modify their physical activities and take care not to get engaged in any type of activities that can trigger or worsen pain and disability such as lifting heavy objects or walking long distances. Practicing good body posture and proper body mechanics can help prevent this spinal condition to a great extent.

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