Careful Coding: With or Without Myelopathy

Clinicians must be on their toes when it comes to the spelling, pronunciation and definition of different anatomical and health care terms. Many terms have similar spelling and pronunciation, and thus can be easily confused. Take the terms myelopathy (spinal cord pathology) and myopathy (muscular pathology).¹ The similarity of their spelling and pronunciation can cause confusion, as is evident in diagnostic coding.

Doctors often confuse the terms myelopathy and myopathy. When this occurs, a disc disorder with radicular signs and symptoms involving the muscularity of the lower extremity (myopathy or without myelopathy) is often diagnosed as a disc disorder with spinal cord involvement (with myelopathy). This can also occur with other conditions that present with or without myelopathy. (Tables 1, 2)² There can be large differences in the signs, symptoms and clinical significance among conditions with similar spelling and pronunciation. Myelopathy and myopathy are perfect examples.

Disc disorders with myelopathy require positive findings for spinal cord pathology, i.e., upper motor neuron lesions. Bilateral extremity paraesthesias, spastic muscle weakness, hyperreflexia and pathological reflexes are among the possible findings. (Table 3)³ Additional findings of thecal sac/cord compression might be seen through advanced imaging.

For disc disorders without myelopathy, positive findings for spinal cord pathology are absent. If any neurological involvement is present, it would be lower motor neuron in nature. Unilateral leg paraesthesia in a dermatome pattern, flaccid muscle weakness, fasciculations, hyporeflexia and the absence of pathological reflexes are among the possible findings. (Table 3)³ Advanced imaging might show a disc lesion touching the thecal sac/cord but, significant compression would not be seen.

The confusion over the prefixes myelo and myo can also be seen in the use of diagnosis codes for spondylitic conditions. Post-traumatic and degenerative spondylitic changes of the spine can also occur with or without spinal cord involvement. Differentiation is again based on the presence or absence of upper and lower motor neuron signs and symptoms. The key diagnostic components of these conditions are the same for spondylitic changes as they are for the disc conditions.

When disorders with myelopathy are identified, the need for referral to a medical spine specialist exists. Care for the patient beyond that point may be concurrent or may become the sole responsibility of the medical clinician. Complete referral is more probable. Chiropractic care of disorders without myelopathy may or may not require referral. If referral is necessary, it would likely to be for concurrent care. Complete referral is less probable.

When considering myopathy (muscular conditions), several conditions are listed in the 359 code range. These codes, however, are for myopathy resulting from immune, inflammatory and clinical illnesses.² The occurrence of these conditions in chiropractic practice is low.

Codes for muscular conditions typically seen in chiropractic practice are found in the 728.0-729.0 range. These conditions (Table 4) are for myopathy resulting from musculoskeletal conditions causing lower motor neuron signs and symptoms.² When present, these myopathies are secondary conditions and should be listed after disc disorders and/or other primary diagnoses.

As can be discerned from the above discussion, proper coding starts with clarity of terminology. From there, proper examination and correlation of the findings into an accurate diagnosis are required. Once the diagnosis is rendered, the proper diagnostic code can be selected. Make the effort to know these conditions, their supportive findings and their appropriate codes.

References

1. Stedman's Medical Dictionary, 28th Edition. Lippincott Williams and Wilkins, Philadelphia, 2006.
2. International Classification of Diseases, 9th revision, Clinical Modification, 6th edition, 2011 Office Edition, Volumes 1 &2. Practice Management Information Corporation (PMIC), Los Angeles, 2010.
3. Jones Jr. HR. Netter's Neurology. Saunders-Elsevier, Philadelphia, 2005.

As the ICD-10 is scheduled for release in 2013 and contains substantially more codes than the ICD-9, providers should make sure they are current on any and all code changes when the new version is released for use.