Lumbar spinal stenosis in easy to understand terms

Lumbar refers to the lower back. The spinal column has spaces that are sometimes narrowed. In the lumbar region, this can tighten the space for nerves that travel to the legs. This is referred to as lumbar spinal stenosis. Often, people do not have any symptoms of lumbar spinal stenosis. But some people report pain, tingling, numbness, heaviness, or weakness of the buttocks or legs.

Where the narrowing occurs

Narrowing in the lumbar region can occur in several locations. The central canal is the main pathway for a bundle of nerves of the lumbar region. The lateral recess is the side of the central canal. The intervertebral foramen is an opening between two adjacent vertebrae. The nerve root leaves the spinal canal through this opening. Imaging can show these structures in a more or less clear way at different levels of the lumbar region.

This anatomy can help explain the differences in the problems people report who have been diagnosed with lumbar spinal stenosis. Central canal stenosis can cause leg symptoms while walking. But, if there is narrowing of a particular nerve root, the person can experience pain or numbness in the leg along the path of that nerve. The clinician relies on the results of a physical examination and the symptoms the patient reports to decide which findings of lumbar spinal stenosis are important.

Common causes

Disk problems and facet joint problems are frequently seen as sources of lumbar spinal stenosis. The disk could bulge, facet joints may hypertrophy, bony outgrowths may form, or ligaments can get thickened. There may also be slippage of one vertebra over another, which is referred to as spondylolisthesis. Some people have a narrow spinal canal by nature, and there can be more than one of these conditions present. The assessment of the provider must focus on determining the main diagnosis and an associated condition, which might affect the coding or treatment. Accurate Medical Coding Services will assist in documenting these conditions properly. According to the American Academy of Orthopedic Surgeons, there is an OrthoInfo article on lumbar spinal stenosis.

Neurogenic claudication and other leg symptoms

Neurogenic claudication describes symptoms that occur with the compression of a spinal nerve. Symptoms can include numbness, tingling, heaviness, and/or weakness. Like vascular claudication, the symptoms occur with activity. However, the symptoms of lumbar radiculopathy ease with activity.

Patients can have more than one condition, and the symptoms described on history and physical can help the provider narrow their differential. Providers can also rule in/out these conditions based upon the patient’s history and examination.

A practical note details what brings on the symptoms, what alleviates the symptoms, and how the symptoms affect function. ‘Legs hurt’ gives little to no information for the treating clinician and the reviewer, whereas ‘Bilateral thigh heaviness with upright walking, eased by sitting, limits walking through the grocery store,’ provides a fuller clinical picture for both parties. The diagnostic assessment provides the code-level conclusion.

Choosing M48.061 or M48.062 from the assessment

M48.061 includes confirmed lumbar stenosis NOS

If an assessment states ‘lumbar spinal stenosis,’ and if that statement is addressed in the plan and there is no conflicting documentation, M48.061 would be correct. The term lumbar spinal stenosis NOS is included in the Tabular List and describes the rationale for selecting the code, thus the wording of the code description does not require a separate negative finding in every chart.

This is relevant if the patient reports symptoms of the back or leg that are nonspecific. The coder can follow the documentation of lumbar stenosis. A patient can experience considerable functional limitation with M48.061, and the code describes the area, claudication, so ensure the level and side of symptoms are described in the narrative.

M48.062 reflects a documented clinical diagnosis

If an assessment states ‘lumbar spinal stenosis with neurogenic claudication,’ then M48.062 is correct. It is the official coding policy to assign code based on the diagnostic statement made by the provider. There are numerous means to communicate the rationale to the reviewer. For this service, the coding decision is based on the documentation.

When the chart says “claudication” without distinguishing the type, and that has an impact on the code selected, ask the provider to clarify. Symptom description from the patient about the shopping cart sign is valuable to the provider. The coder should not transform the symptom to a diagnosis.

There are different rules for office and imaging visits

For an office visit, review the clinician’s final assessment and reason for the service. If the clinician states only leg pain and refers to lumbar stenosis as a possibility, then use the outpatient uncertain diagnosis rule and report the supported symptom or reason for the visit. If lumbar stenosis is confirmed, and neurogenic claudication is still a possibility, then M48.061 could be assigned for the confirmed diagnosis.

For an outpatient visit solely for diagnostic testing, according to the Official Guidelines, Section IV.K, coding definitive diagnoses from the final physician’s interpretation is allowed if that report is available for coding. A definitive diagnosis of lumbar stenosis supports the code for that imaging service, in accordance with the reporting and coding instructions. A finding of narrowing on MRI is not sufficient to determine the clinical syndrome of neurogenic claudication.

Excludes1 and Excludes2 and related diagnoses

Read the notes at the level where they apply

An Excludes1 note generally prevents the reporting of the excluded code with the reporting code. The exception to the general rule is if the conditions are clearly unrelated. If the relationship is unclear, seek clarification from the provider. An Excludes2 note indicates that the excluded condition is outside the scope of the code. Both conditions may be reported if they exist and if they also meet the reporting requirements.

In the Tabular List, there are no separate Excludes1 or Excludes2 notes for M48.0, M48.06, M48.061, or M48.062. Chapter level notes still apply. For example, in the Musculoskeletal chapter, there is an Excludes2 note for Congenital Malformations. If the Provider documents Lumbar Stenosis and a different Congenital Malformation, review the Coding instructions for both, and clarify with the Provider if needed. If the assessment describes a Congenital abnormality as the only diagnosis, code it directly.

Radiculopathy and Disc disorders

The Excludes1 note at M54.1 applies to M54.16. It includes Radiculopathy with Lumbar or other intervertebral disc disorders and Radiculopathy with Spondyolysis. The Alphabetic and Tabular lists are used to determine if a combination code describes both aspects of the diagnosis. A Provider assessment stating “Lumbar Disc Herniation with Radiculopathy” supports the reporting of M51.16. Adding M54.16 would be a duplicate diagnosis.

The stenosis code will be reported separately from the diagnosis that justifies the lumbar stenosis if the lumbar stenosis affects treatment. If the evaluation identifies lumbar stenosis based on the documented diagnosis and applicable notes, the stenosis code should be reported. The presence of a disc bulge and leg pain on different parts of the record could be a reason to review the assessment and the Index, if the relationship is not clear or the record is in conflict.

Lumbar disc degeneration is distinct from disc displacement. If lumbar disc degeneration is documented and it is impacting the care provided, review the documented pain pattern and relevant child codes under M51.36. Disorder of the disc requires the establishment of the diagnosis by the clinician and specificity of the classification.

Spondylolisthesis, foraminal stenosis and cauda equina syndrome

Spondylolisthesis refers to slippage of vertebrae. M43.16 covers Lumbar Spondylolisthesis. Determine if the clinician diagnosed both the slippage and stenosis, and if both of these impacted treatment. Slippage may be mentioned incidentally on imaging and do not always require surgical intervention. However, if the slippage is diagnosed by the surgeon, and intervention is planned, then it may warrant a different code.

Foraminal stenosis refers to where the narrowing occurs. The causes for this may be soft or hard tissue, and are covered by M99.63 and M99.73, respectively. If a more appropriate category for the condition is found, this condition can be classified as elsewhere using the Index and the M99 instruction. Use of vague words such as “lumbar foraminal stenosis” may not fully describe what caused the stenosis. If the use of vague words is done to facilitate understanding the diagnosis and code choice, it may be appropriate.

Cauda Equina syndrome is represented by G83.4, and it may also be appropriate to evaluate the cause(s) of this syndrome using the Official Index and Tabular List. M48.062 describes Neurogenic Claudication and it should not be used to represent Cauda Equina Syndrome.

Outpatient chart examples and documentation tips

These examples use fictional records. Each turns on a decision that can change the diagnosis code or how the claim is sequenced.

Sample Assessment With Enough Detail to Code

Assessment Lumbar spinal stenosis with neurogenic claudication. Bilateral calf heaviness with upright walking improves with sitting and limits trips through the grocery store. MRI of the lumbar spine shows central canal stenosis at L1-L2 consistent with the symptoms.

Plan Discussed the examination and imaging results. Referred to physical therapy to address gait and walking tolerance.

For code selection, the assessment includes the diagnosis of lumbar spinal stenosis with neurogenic claudication. The rest of the note correlates diagnosis to function and plan. A clinician can record the pertinent level and side as well as exam findings and the response to care to help explain a procedure or therapy service. M48.061 and M48.062 do not have a laterality variant.

Example of a Neutral Query for a Conflicting Assessment

There is one signed assessment describing lumbar stenosis without neurogenic claudication. There is a second assessment describing lumbar stenosis with neurogenic claudication for this visit. The patient has leg heaviness with walking and symptoms improve with sitting. Please determine the status of neurogenic claudication associated with lumbar stenosis, if possible.

An EHR template may provide a place for the clinician to document status as present, absent, unclear or unassessed. Leave the field blank to allow for clinician’s judgment. In a coding review, check to see if the assessment and plan support the code. A prepopulated status may cause a documented conflicting assessment that the coder will have to resolve.

Clinical evaluation and treatment options

The exam adds context to the scan

Clinicians want to know where the symptoms occur, what activities bring them on, and what alleviates them. They may check strength, sensation, reflexes and gait and consider other sources of leg symptoms including vascular or hip pathology. A patient describing how far they can walk or what tasks they avoid provides the clinician with more information than a pain score.

An MRI can show the discs and nerves and the surrounding areas. Alignment or slippage of the vertebrae can be seen on X-ray. A CT may also be useful. The appropriate imaging test depends on the clinical question and the patient’s situation. The American Academy of Orthopaedic Surgeons provides patient information about the tests and what they show.

If the word “severe” is used in your report, ask your clinician what findings correlated to your symptoms and what it means for your management. The answer may impact your treatment plan.

Treatment is based on symptoms and functional limits

Treatment may include activity or lifestyle changes, or physical therapy and pain management, which may focus on improving movement and/or strength and walking tolerance. If symptoms are not improved, your clinician may discuss other options, which may include an injection. The benefit and risk of the injection or other treatment is based on the cause of your symptoms and the patient.

A spine specialist may suggest decompression when symptoms limit normal function and do not improve with nonsurgical methods. In addition, if there are neurological symptoms or findings, a spine specialist may recommend surgical decompression. An ideal candidate for spinal fusion is often someone with instability in the spinal column. Stability is often addressed by performing decompression. While a diagnosis code may help determine the best course of action, it often takes a combination of diagnosis and examination findings to help determine the best course of action.

Symptoms that require immediate evaluation. Loss of bladder and bowel control, and numbness in the groin or the saddle area are symptoms of cauda equina syndrome. Call 911 or go to the nearest emergency room for these symptoms.

Claim checks that prevent avoidable corrections

Confirm complete code and first-listed diagnosis

If an exact match is found for M48.06, a claim check will prevent an avoidable correction. A rule that flags anything that begins with M48.06 will also capture valid child codes. Ensure that the EHR does not default to the parent code and review how the code is transmitted from the chart to the claim.

In an outpatient setting, the first listed diagnosis should describe the condition that is the reason for the visit the most. However, other conditions that are present but do not affect the plan of care do not need to be documented. Symptoms that support the diagnosis remain in the history and are not coded. An independently verified symptom may be coded if it is one of the reasons for the visit and affects care or treatment.

Policy Check against applicable policy

A diagnosis code is not enough evidence for the whole claim. It needs to provide justification for the HCPCS/CPT code, site of service or level, and coverage/authorization as needed by the payer. For instance, a valid lumbar stenosis code will support an injection referral, but the payer may still ask for the indication, imaging correlation, previous treatment, and plan of care.

The Original Medicare claims should be validated against the CMS Medicare Coverage Database, specifically the relevant national/local coverage and billing articles. There may be some explanation about the clinical indications and allowable diagnosis codes in the coverage policy of the Medicare contractor. Medicare Advantage and commercial insurance may have a different coverage and authorization process, and thus it is necessary to validate the plan. Medical Billing Services can assist in this process.

Send route rejections and denials to the correct review

A clearinghouse rejection for an incomplete code requires a code-to-record check. If the claim uses M48.06, confirm which reportable child code the assessment supports. A payer denial for medical necessity requires a review of the remittance, the billed service and the relevant policy. Use the payer’s correction or appeal process as appropriate. Change the diagnosis code only if the documentation supports a change.

Other issues such as use of M48.061/062 by the same assessor at the same time may be uncovered by a survey. Report any inconsistent or conflicting diagnosis. Include missing authorization and service documentation. In the survey, include a sample of claims supported by signed assessments for M48.061 and 062. If the same problem occurs, report to the individual who is in control of the template, claim edit or authorization workflow.