Health Information Management

Q&A: Coding stenosis with spondylosis

JustCoding News: Outpatient, January 8, 2014

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Q: A patient presents with lower back pain and the physician documents findings of stenosis, degenerative “changes,” and mild facet arthropathy. Which diagnosis codes should we report?
I would code 724.02 (stenosis, lumbar region, without neurogenic claudication) and 721.3 (lumbosacral spondylosis without myelopathy) for the facet degeneration. Another coder has stated that I cannot code 724.02, as the 721.3 diagnosis code will exclude the use of 724.02. Can you help with this scenario?
 
A: The other coder is correct that 724.0 and 721.3 cannot be coded together, but it’s the other way around. There is an Excludes note beneath code category 724 citing conditions due to spondylosis (721.0-721.9).
In addition to 724.02, have you considered including 716.88 (other specified arthropathy, other specified sites)? And/or, perhaps 733.90 (disorder of bone and cartilage) to report the degenerative “changes”? It is difficult for me to be more specific without seeing the complete documentation.
 
Editor’s note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, Fla., answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
Need expert coding advice? Submit your question to Editor Steven Andrews at sandrews@hcpro.com, and we’ll do our best to get an answer for you.
 



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