Dont Get Nervous About Reporting Neurology

Diagnoses
By Susan Dooley

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, dont 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.

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

Heres 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, heres 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 weaknesss 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? Wed love to hear them! Let us know.

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

Need the Ideal Coding Tool? Get Physician Coder!

Physician Coder gives you code search for CPT, HCPCS, ICD-10-CM, and with the 7-in-1 Fee Schedule it
helps you find RVUs for a specific CPT code, too. Its CMS 1500 Real-Time Scrubber gives you instant
advice so you can correct the claim before it goes to the clearinghouse. Plus, you get the specialty
coding newsletter of your choice! Theres so much more that Physician Coder has to offer practices
cant afford to be without it. Check it out here!
Contact us for a free trial or a demo today!

Contact Us:
Name: Sam Nair
Title: Associate Director
Email: shyamn@codinginstitute.com
Direct: 704 303 8150

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com