From History to ICD-10 Code - Doctor’s Thinking - KMC University

From History to ICD-10 Code - Doctor's Thinking

Doctors begin formulating the diagnosis from the moment the consultation is initiated. In this visual example, we can see the facts and doctor's thinking at each stage of the evaluation. The process is demonstrated and developed through to the final diagnosis and appropriate, reported ICD-10 codes. This example demonstrates a chronic lumbar complaint.

Patient Presentation and History 59 y/o male; chronic low back pain (6/10) aggravated by lifting; responded well to care with past lifting injuries; pain radiating to medial aspect of lower leg; can't sit for longer than 5 minutes or rest comfortably

Additional Considerations Pain relieved in certain positions, lessens with walking, but not alleviated by forward bending. Trial of care prior to ordering MRI if no improvement.

Diagnosis Option Consideration ? Sciatica (Radiation in medial aspect of leg) ? Stenosis (Not alleviated by forward bending) ? Lumbar Disc Degeneration ? Possible Lumbar Disc Displacement ? Possible Intervertebral disc disorders

with radiculopathy, lumbar region ? Lumbar Segmental Dysfunction ? Lumbar Facet Syndrome ? Spondylosis with radiculopathy

Highest Level of Specificity ? Lumbar Disc Degeneration (Primary) ? Spondylosis with radiculopathy (Secondary) ? Lumbar Segmental Dysfunction (Secondary) ? Lumbar Facet Syndrome (Secondary)

? ?

!

Initial Diagnosis Options ? Lumbar Disc Displacement ? Spinal Stenosis ? Lumbago with Sciatica ? Spondylosis with radiculopathy ? Lumbar Disc Degeneration ? Lumbar Facet Syndrome ? Lumbar Segmental Dysfunction ? Intervertebral disc disorders with

radiculopathy, lumbar region

Exam Findings ? Decreased muscle strength, left leg and

decreased L/S ROM with pain, reflexes WNL ? Positive Findings: localized SLR left, Kemps ? Negative Findings: Nachalas, Yeomans, Milgrams ? Rationale for Lumbar AP/LAT: Over 50 y/o; pain greater than 4/10 VAS

X-ray Findings ? Disc degeneration at L4/L5 ? Mild degeneration throughout

Lumbar spine

Locate and Report Codes-1500 Form Hierarchy

? M51.36 - Other intervertebral disc degeneration, lumbar

? M47.26 - Other spondylosis with radiculopathy, lumbar

? M99.03 ? Lumbar segmental dysfunction

*M47 ICD-10 Chapter notes: "includes arthrosis or osteoarthritis of spine and degeneration of facet joints"- No need to separately code Lumbar Facet Syndrome

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