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Diagnoses
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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713,
Eenterprise Contact: Sam Nair, Direct: 704 303
8150,[email protected]
Dont Get Nervous About Reporting NeurologyDiagnoses
By Susan Dooley
Nervous system diagnoses can seem complicated to report, but let
these tips guide you in reportingthese common conditions.
What a Pain! Is It Chronic, Central, or Chronic Pain
Syndrome?
The diagnosis names sound so similar, but chronic and central
pain and chronic pain syndrome are very
different from both clini cal and coding standpoints. First of
all, speaking of pain, dont report pain as adiagnosis unless the
reason for the encounter is pain control or management of pain, not
a treatmentfor the underlying condition. If the provider documented
the pain as acute or chronic, you can choosean appropriate code
from category G89. Report the code from G89 first, followed by the
site if theencounter is specifically for pain management. By the
way, there is no time frame required to classifypain as chronic,
just specific documentation saying the pain is indeed chronic.
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Diagnoses
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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713,
Eenterprise Contact: Sam Nair, Direct: 704 303
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Heres an example. A 72 -year-old female presents to the pain
management clinic complaining ofintractable, persistent pain in the
low back status post a motor vehicle accident two years prior.
Shepresents to undergo nerve block. In this case, you would report
the following diagnosis codes:
G89.21, Chronic pain due to trauma M54.5, Low back pain.
Note that the above documentation does not support a diagnosis
of chronic pain syndrome. Thiscondition includes chronic pain, of
course, but the pain is accompanied by significant
psychosocialdysfunction, including problems such as depression,
drug dependence, anxiety, or complaints out ofproportion to the
physical findings. If the documentation specifies chronic pain
syndrome, then reportthis:
G89.4, Chronic pain syndrome.
Another very similar sounding condition to these is central pain
syndrome. But watch out, because
central pain syndrome is different from chronic pain syndrome.
Central pain syndrome is a neurologicalcondition caused by damage
to the central nervous system (CNS), or caused by dysfunction of
the CNS.The syndrome can be caused by stroke, multiple sclerosis,
tumors, epilepsy, brain or spinal cord trauma,or Parkinson disease.
If your provid er documents central pain syndrome, heres what to
report:
G89.0, Central pain syndrome.
You Say Tomato, I Say Tomahto Check Out This Tip for
ReportingHemiplegia and Hemiparesis
How do you code this scenario? A 79-year-old male is admitted to
the hospital with gastrointestinalbleeding. The patient, who is
right handed, was recently discharged from this facility after
acute cerebralinfarction with residual right-sided weakness. Report
this scenario with this diagnosis code:
I69.351, Hemiplegia and hemiparesis following cerebral
infarction affecting right dominant side.
Volume 2, number 1 of the AHA Coding Clinic for ICD-10-CM and
ICD-10-PCS, vol. 2, no. 1, from 2015explains that even though the
words hemiplegia and hemiparesis were not used in this scenario, as
longas the provider relates the weaknesss cause as a CVA, it is
considered synonymous with hemiparesis orhemiplegia. If unilateral
weakness exists but is not clearly associated with a stroke,
thenhemiparesis/hemiplegia cannot be assumed.
What About You? Got any special tips or tricks for neurology
coding that we missed? Wed love to hear them! Let us know .
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Diagnoses
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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713,
Eenterprise Contact: Sam Nair, Direct: 704 303
8150,[email protected]
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Contact Us:
Name: Sam Nair
Title: Associate Director
Email: [email protected]
Direct: 704 303 8150
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC
27713
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]
