Don’t Get Nervous About Reporting Neurology Diagnoses

Mon, Jun 13, 2016 --

ICD-10

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Nervous system diagnoses can seem complicated to report, but let these tips guide you in reporting these 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 clinical and coding standpoints. First of all, speaking of pain, don’t report pain as a diagnosis unless the reason for the encounter is pain control or management of pain, not a treatment for the underlying condition. If the provider documented the pain as acute or chronic, you can choose an appropriate code from category G89. Report the code from G89 first, followed by the site if the encounter is specifically for pain management. By the way, there is no time frame required to classify pain as chronic, just specific documentation saying the pain is indeed chronic.

Here’s an example. A 72-year-old female presents to the pain management clinic complaining of intractable, persistent pain in the low back status post a motor vehicle accident two years prior. She presents 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. This condition includes chronic pain, of course, but the pain is accompanied by significant psychosocial dysfunction, including problems such as depression, drug dependence, anxiety, or complaints out of proportion to the physical findings. If the documentation specifies chronic pain syndrome, then report this:

  • 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 neurological condition 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 provider documents central pain syndrome, here’s what to report:

G89.0, Central pain syndrome.

You Say Tomato, I Say Tomahto — Check Out This Tip for Reporting Hemiplegia and Hemiparesis

How do you code this scenario? A 79-year-old male is admitted to the hospital with gastrointestinal bleeding. The patient, who is right handed, was recently discharged from this facility after acute cerebral infarction 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 2015 explains that even though the words hemiplegia and hemiparesis were not used in this scenario, as long as the provider relates the weakness’s cause as a CVA, it is considered synonymous with hemiparesis or hemiplegia. If unilateral weakness exists but is not clearly associated with a stroke, then hemiparesis/hemiplegia cannot be assumed.

What About You?

Got any special tips or tricks for neurology coding that we missed? We’d love to hear them! Let us know in the comment box below.

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About 

Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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1 Comments For This Post

  1. Taylor Hicken Says:

    I think it’s crazy that there can be lower back pain, just due to neck injuries. My husband got into a crash a few weeks ago, except he didn’t think he any major injuries. We’ll have to get to a doctor to see if there’s any major issues going on.

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