Musculoskeletal condition M47.24 — ICD-10 M47.24

ICD-10: M47.24 | Category: Spine Disorders | Billable: Yes

ICD-10 code M47.24 refers to "Cervical spondylosis with radiculopathy," a degenerative condition affecting the cervical spine characterized by the wear and tear of spinal discs and joints. This condition is prevalent among older adults, typically manifesting as neck pain, stiffness, and neurological symptoms due to nerve root compression. Cervical spondylosis can lead to significant morbidity if not properly diagnosed and managed.

The cervical spine comprises seven vertebrae (C1-C7) that support the head and facilitate its movement. Each vertebra is separated by intervertebral discs, which act as shock absorbers and allow flexibility. The spinal cord runs through the vertebral foramen, with nerve roots branching out from the spinal cord at each level.

Biomechanically, the cervical spine is designed for a wide range of motion, including flexion, extension, lateral bending, and rotation. This mobility is essential for daily activities but also predisposes the cervical spine to degenerative changes over time. The facet joints provide stability during movement, while ligaments and muscles support the spine's integrity.

Patient presents with chronic lower back pain radiating down the left leg and numbness in the left foot after lifting heavy boxes at work. Upon examination, the physician identifies signs of spondylosis with radiculopathy. Code as M47.24 because the patient's symptoms and examination findings support a diagnosis of other spondylosis with associated radiculopathy, meeting the criteria outlined in ICD-10-CM guidelines.

To support medical necessity and prevent claim denials for ICD-10 code M47.24, the following documentation elements are critical:

• Comprehensive Patient History: Include a detailed history of the patient’s symptoms, including onset, duration, and exacerbating factors.

• Physical Examination Findings: Document specific findings related to the lumbar region, including range of motion, tenderness, and neurological assessments.

• Diagnostic Imaging Reports: Ensure that imaging studies (e.g., MRI, X-rays) are referenced in the documentation, highlighting findings that correlate with the diagnosis.

• Treatment Plan Details: Clearly outline the medical necessity for prescribed treatments, including physical therapy and medications, as well as rationale for follow-up appointments.

• Referral Information: If applicable, document any referrals to specialists for further evaluation or management of the condition.

Subjective: A 57-year-old female patient reports persistent lower back pain for the past six months that sometimes radiates down her right leg. She notes that the pain worsens after prolonged sitting or standing and describes a tingling sensation in her right foot. Objective: Physical examination reveals tenderness in the lumbar region and decreased range of motion. Neurological assessment shows mild weakness in the right lower extremity and diminished reflexes. Imaging studies, including an MRI, indicate disc degeneration at the L4-L5 level with evidence of nerve root compression. Assessment: The patient is diagnosed with other spondylosis with radiculopathy (M47.24) based on clinical findings and imaging results. Plan: Initiate a treatment plan that includes physical therapy focusing on strengthening and stretching exercises, prescribe non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief, and schedule a follow-up appointment in four weeks to reassess symptoms.

Several conditions may present similarly to cervical spondylosis with radiculopathy:

• Herniated Disc (M51.26): A herniated cervical disc may cause similar radicular symptoms but usually presents acutely following trauma or heavy lifting.
• Cervical Radiculopathy without Spondylosis (M54.12): This condition refers specifically to radicular symptoms without degenerative changes evident on imaging.
• Cervical Stenosis (M48.02): Spinal canal narrowing can lead to similar symptoms but often involves more significant neurological impairment.
• Thoracic Outlet Syndrome (G54.0): Compression of neurovascular structures can mimic radicular pain but typically includes upper extremity vascular symptoms.

Proper documentation is crucial for accurate billing under ICD-10 code M47.24:

1. Document patient history comprehensively, including onset, duration, severity of symptoms, and previous treatments attempted.
2. Include findings from physical examinations and imaging studies that support the diagnosis.
3. Outline treatment plans clearly along with patient responses to various interventions.

Billing codes should reflect both the diagnosis (M47.24) and any associated procedures or treatments provided during visits.