Find information on neural foraminal stenosis diagnosis, including ICD-10 codes, clinical documentation requirements, and treatment options. Learn about symptoms, causes, and the latest diagnostic criteria for neural foraminal narrowing. This resource offers guidance for healthcare professionals on proper coding and documentation for spinal stenosis of the neural foramen, radiculopathy, and related nerve compression syndromes. Explore effective strategies for accurate clinical documentation and appropriate medical billing for neural foraminal stenosis.
Also known as
Spinal stenosis
Narrowing of the spinal canal causing pressure on nerves.
Cervical radiculopathy
Pinched nerve in the neck, often causing pain and weakness.
Thoracic radiculopathy
Pinched nerve in the mid-back, often causing pain and numbness.
Lumbosacral radiculopathy
Pinched nerve in the lower back, often causing pain and sciatica.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the neural foraminal stenosis specified as cervical?
When to use each related code
| Description |
|---|
| Neural foraminal narrowing |
| Lateral recess stenosis |
| Central canal stenosis |
Missing documentation of affected side (right, left, bilateral) and specific spinal level for accurate coding (e.g., M54.1X). Impacts reimbursement.
Confusing stenosis as cause of radiculopathy. Code the underlying cause, not the stenosis itself, if documented. Impacts DRG assignment.
Insufficient clinical evidence to support M54.1X. Ensure documentation clearly links stenosis to neurological findings for accurate coding and compliance.
Patient presents with complaints consistent with neural foraminal stenosis. Symptoms include radicular pain, radiating pain, numbness, tingling, and weakness, localized to the affected dermatome. The patient reports pain exacerbated by activities such as extension, rotation, or lateral bending of the spine. On physical examination, there may be limited range of motion, muscle weakness, sensory deficits, and positive findings on Spurling's test or the straight leg raise test. Differential diagnoses considered include herniated disc, degenerative disc disease, spondylosis, facet joint arthritis, and spinal stenosis. Imaging studies, such as MRI, CT scan, or X-ray, may be ordered to confirm the diagnosis of neural foraminal stenosis and assess the degree of nerve compression. Initial treatment plan may include conservative management with pain medication, physical therapy, chiropractic care, and epidural steroid injections. Surgical intervention, such as foraminotomy or laminectomy, may be considered if conservative treatment fails to provide adequate relief. Patient education regarding proper posture, body mechanics, and activity modification is crucial. Follow-up appointments will be scheduled to monitor symptom progression and adjust treatment as needed. ICD-10 code M48.06 (Neural foraminal stenosis) and relevant CPT codes for procedures performed will be used for billing purposes.