Diagnosing, Documenting, and Coding for Radiculopathy

Radiculopathy can be an unpleasant condition, but diagnosing, documenting, and coding for it does not have to be. It just takes a little research.

As you know, the brain communicates with the body via the spinal cord, which is protected by the bones of the spinal column, called vertebrae. Nerve roots exit in between each bone through openings called foramen. The nerves from the neck carry signals back and forth to and from the arms, hands, and fingers. Cervical radiculopathy is the name for pain and other symptoms caused by problems with these nerves. Problems with the nerves from the lower back can cause symptoms in the legs and feet; this is called lumbar radiculopathy (or sometimes, sciatica).

Diagnosing radiculopathy can be done with a variety of orthopedic, neurological, and imaging procedures. Orthopedic tests reproduce the symptoms by increasing pressure or stress on the affected nerves. You might see documentation with names like “Straight Let Raiser,” “Braggard’s,” “Lasegue’s,” and “Berchterew’s.” Common neurological tests for nerve-related disorders include pinwheel, muscle strength, deep tendon reflexes, needle EMG, and nerve conduction velocity tests. These tests identify if the nerves are functioning properly. In many cases diagnostic imaging is also helpful to identify the source of the nerve irritation, such as a herniated intervertebral disc, so an MRI report might be found in the record. A medical record with a diagnosis of radiculopathy would be expected to include at least some of these tests.

If M54.17, Lumbosacral radiculopathy is reported, the following is an example of typical documentation that would support it.

Subjective: Patient is a 55-year-old male who has worked on the docks, engaged in heavy labor, for 25 years. He reports numbness and shooting pain from the right buttock to the right posterior thigh and lateral ankle/foot, which increases with sneezing or coughing.

Objective: Decreased sensation via pinwheel testing along right S1 dermatome. Lasegue’s test reproduces the symptoms. Ankle plantar flexion and eversion is 4 out of 5 on the right. Achilles reflex is absent on the right.

Radiculopathy codes in ICD-10 are found in the M54.1- subcategory, part of the block M50-M54, Other Dorsopathies, within Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue (M00–M99). There are nine code choices, with the fifth and final character designating the spinal region associated with the radiculopathy. Interestingly, laterality is not an option for these codes, though the side of the body still should be documented. There are five inclusion terms, which are a listing of synonyms or additional conditions assigned to that code.   They include the following:

  • Brachial neuritis or radiculitis NOS
  • Lumbar neuritis or radiculitis NOS
  • Lumbosacral neuritis or radiculitis NOS
  • Thoracic neuritis or radiculitis NOS
  • Radiculitis NOS

Some providers may prefer to distinguish between these conditions, and in fact, one of the reasons for the transition to ICD-10 was increased specificity. In this case, clinicians do not have that option.

Though definitions vary, radiculopathy is a general term for the condition of spinal nerve root problems, including paresthesia, hyporeflexia, motor loss, and pain. Neuritis is inflammation of a peripheral nerve and radiculitis is defined as inflammation of a spinal nerve along its path of travel, such as a dermatome. The M54.1- subcategory includes them all. Documentation of any one of the inclusion terms would be reported with these codes.

It is also important to note that other diagnosis codes, such as M50.1- Cervical disc disorder with radiculopathy, or M47.2- Other spondylosis with radiculopathy, are radiculopathy combination codes that also denote the cause of the nerve irritation. In these cases, it would not be necessary to also use a code from the M54.1- subcategory. In fact, these codes are preferred because they provide a more definitive diagnosis and therefore better justify medical necessity.

Some sources consider the term “sciatica” to be synonymous with lumbar or lumbosacral radiculopathy, but the code set offers separate codes (M54.3- sciatica and M54.4- lumbago with sciatica). It is interesting that these codes do offer right or left designations while the radiculopathy codes do not. It may help to differentiate sciatica by defining it as numbness, tingling, weakness, and/or leg pain that originates in the buttock and travels down the path of the sciatic nerve in the back of the leg. However, radiculopathy will follow the path of the nerve root as it exits the spinal column. This pattern often wraps around the leg rather than following the sciatic nerve down the posterior of the leg.

Diagnosing, documenting, and coding for radiculopathy may seem complex. However, a thorough understanding of the condition and coding options will make it simple for a provider who does a little homework.

About the Author 

Dr. Gwilliam, vice president of the ChiroCode Institute and FindACode, graduated from Palmer College of Chiropractic as valedictorian and is a certified professional coding instructor, medical compliance specialist, and certified professional medical auditor. He now provides expert witness testimony, medical record audits, consulting, and online courses for healthcare providers. He also writes books and articles for trade journals, and is a sought-after seminar speaker. He has a bachelor’s degree in accounting, a master’s of business administration, and is one of the few clinicians who became a certified ICD-10 Instructor through the American Academy of Professional Coders.

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Photo courtesy of: ICD10 Monitor

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