ICD-10 Coding for Spinal Stenosis, Cervical Region(M48.02)
Complete ICD-10-CM coding and documentation guide for Spinal Stenosis, Cervical Region. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Spinal Stenosis, Cervical Region
M48.0-M48.03Primary Range
Spinal stenosis codes for different regions
This range includes codes for spinal stenosis in various regions, with M48.02 specifically for the cervical region.
Key Information: ICD-10 code for spinal stenosis cervical region
Essential facts and insights about Spinal Stenosis, Cervical Region
Primary ICD-10-CM Code for spinal stenosis cervical region
Decision Criteria
clinical Criteria
- MRI confirms stenosis at C2-C7
documentation Criteria
- Documentation specifies cervical level
Clinical Validation Requirements
- MRI showing spinal canal narrowing at C2-C7
- Clinical symptoms of neurogenic claudication or radiculopathy
Code-Specific Risks
- Risk of using unspecified code M48.00 when specific level is documented
Coding Notes
- Ensure documentation specifies the exact cervical level affected.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Spinal Stenosis, Cervical Region to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M48.02.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Train staff on documentation requirements, Use templates that prompt for specific levels
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Ensure documentation specifies the exact level and use the corresponding specific code.
Impact
Risk of audits due to use of unspecified codes when specific codes are available.
Mitigation Strategy
Ensure documentation specifies exact cervical levels and use corresponding codes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Spinal Stenosis, Cervical Region, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Spinal Stenosis, Cervical Region
Use these documentation templates to ensure complete and accurate documentation for Spinal Stenosis, Cervical Region. These templates include all required elements for proper coding and billing.
Cervical stenosis with myelopathy
Specialty: NeurosurgeryRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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