Say what you will, but there are tons of ICD-10-CM Codes used for the different spine conditions. Even if you are not a newbie coder–it can be confusing. This post is not about all the different codes, but just one specific note for the M50 series. If you look at M50, you will see, ‘Note: Code to the most superior level of the disorder.’ If you’ve never noticed this before, please go check it out in the ICD-10 book right now. Below is a pic of my book and the note is highlighted in orange.
So the long and short of it is, you only need to code the disorder for the highest level that’s documented in the report. So say if you’re coding an MRI and the dx is cervical disc disorders with myelopathy, and it’s documented at the C3-C4 level and also C5-C6 in the report–you would only code M50.01. You do not need the code M50.021. I can’t tell you how many times I see coders make this mistake. Here’s the kicker, sometimes it’s not even coders who make this mistake. Sometimes it’s a coding engine. But bear in mind though that there’s no way a coding engine can ‘know’ all the rules. But as coders we have no excuse. When all is said and done, we really just have to know this stuff.