Health Information Management

Q&A: Coding for chronic lower back pain from spinal stenosis

HIM-HIPAA Insider, August 9, 2011

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Q: A patient has chronic lower back pain from spinal stenosis. Should I code chronic lower back pain and spinal stenosis, or only spinal stenosis?

A: According to the ICD-9-CM Official Guidelines for Coding and Reporting, Section II (Selection of Principal Diagnosis), coders may not use codes for symptoms, signs, and ill-defined conditions from Chapter 16 as a principal diagnosis when the physician documents related definitive diagnosis.
 
In this particular scenario, chronic lower back pain (ICD-9-CM code 724.2) is a symptom of spinal stenosis. Therefore, you should code spinal stenosis (ICD-9-CM code 724.00, spinal stenosis, unspecified region) as the correct principal diagnosis.
 
Do not code chronic lower back pain.
 
Editor’s note: Sandra L. Sillman, RHIT, PAHM, a DRG coordinator at Henry Ford Hospital & Health Network, answered this question in the August issue of Briefings on Coding Compliance Strategies.



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