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Q&A: Reporting lower back pain related to lumbar spinal stenosis

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

ANSWER: Codes for symptoms, signs, and ill-defined conditions from Chapter 16 may not be used as a principal diagnosis when a related definitive diagnosis has been established, according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section II (Selection of Principal Diagnosis).

In this particular scenario, lower back pain (ICD-9-CM code 724.2) is a symptom of spinal stenosis. Therefore, the correct principal diagnosis is spinal stenosis (ICD-9-CM code 724.02, spinal stenosis, lumbar region without neurogenic claudication).

Do not code lower back pain.

Regarding ICD-10-CM, codes for symptoms, signs, and ill-defined conditions from Chapter 18 may not be used as a principal diagnosis when a related definitive diagnosis has been established, according to the ICD-10-CM Official Guidelines for Coding and Reporting, Section II (Selection of Principal Diagnosis).

In this particular scenario, lower back pain (ICD-10-CM code M54.5) is a common symptom of spinal stenosis. Therefore, the correct principal diagnosis is spinal stenosis (ICD-10-CM code M48.06, spinal stenosis, lumbar region). In the 2011 ICD-9-CM Manual, CMS added specificity to identify the presence of neurogenic claudication, however this particular addition has not yet been included in the 2011 ICD-10-CM Manual.

Another point of note is that in ICD-10-CM, there are specific codes to identify when the stenosis spans contiguous levels. For example, ICD-10-CM code M48.03 is for stenosis, cervicothoracic. In ICD-9-CM these would be assigned separate codes for cervical and thoracic. In ICD-9-CM lumbosacral is in the Alphabetical index but is assigned to the lumbar stenosis code. In ICD-10-CM, there is a specific code for lumbosacral stenosis—M48.07.

Editor’s note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and Coding for HCPro, Inc., and Sandra L. Sillman, RHIT, PAHM, DRG coordinator who performs inpatient coder and physician education at Henry Ford Hospital & Health Network, answered this question. E-mail questions for McCall to Managing Editor Doreen V. Bentley, CPC-A, at dbentley@hcpro.com. Contact Sillman at ssillma1@hfhs.org.

This Q&A was adapted from one that was published in the Coding Q&A insert in the August issue of Briefings on Coding Compliance Strategies.

Need expert coding advice? Submit your question to Managing Editor Doreen Bentley, CPC-A, and we’ll do our best to get an answer for you.