Find information on cervical spinal stenosis diagnosis, including ICD-10 codes (M48.0, M48.00, M48.01, M48.02, M48.03), clinical documentation requirements, differential diagnosis considerations, treatment options, and healthcare resources. Learn about symptoms, such as neck pain, arm pain, and numbness, related to cervical spinal stenosis and how healthcare providers approach this diagnosis in medical coding and clinical practice. This resource aims to provide comprehensive information for healthcare professionals, coders, and patients seeking to understand cervical spinal stenosis.
Also known as
Spinal stenosis, cervical region
Narrowing of the spinal canal in the neck.
Cervical disc disorders
Problems with the discs between neck vertebrae.
Cervicocranial syndrome
Neck pain affecting the head and neck movement.
Other postprocedural pain
Pain following a spinal procedure in the neck.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the cervical spinal stenosis congenital?
Yes
Code Q76.1 Congenital spinal stenosis, cervical region
No
Is there myelopathy?
When to use each related code
| Description |
|---|
| Cervical Spinal Stenosis |
| Cervical Spondylosis |
| Cervical Radiculopathy |
Coding cervical spinal stenosis without specifying the affected vertebral level(s) leads to inaccurate coding and potential claim denials. Proper documentation is crucial.
Coding symptoms like pain or radiculopathy instead of the underlying diagnosis of cervical spinal stenosis can lead to underpayment and data inaccuracies.
Failure to document and code the laterality (right, left, or bilateral) of cervical spinal stenosis can result in coding errors and affect reimbursement.
Patient presents with complaints consistent with cervical spinal stenosis. Symptoms include neck pain, radiating arm pain, numbness, tingling, and weakness in the upper extremities. The patient reports difficulty with fine motor skills and occasional gait disturbances. On physical examination, range of motion in the cervical spine is reduced, with noted pain on extension and rotation. Spurling's maneuver and Hoffman's sign may be positive. The patient's symptoms suggest nerve root compression and myelopathy. Differential diagnosis includes cervical radiculopathy, herniated disc, degenerative disc disease, and osteoarthritis of the cervical spine. Imaging studies, such as MRI of the cervical spine, will be ordered to confirm the diagnosis and assess the severity of spinal canal narrowing. Initial treatment plan includes conservative management with physical therapy, pain medication including NSAIDs, and cervical epidural steroid injections. Surgical intervention, such as laminectomy or foraminotomy, may be considered if conservative treatment fails to provide adequate relief or if neurological deficits progress. Patient education regarding cervical spinal stenosis, its causes, and treatment options will be provided. Follow-up appointment scheduled to monitor symptom progression and response to treatment. ICD-10 code G99.2, Cervical spinal stenosis, will be utilized for billing and coding purposes.