Cervical Disc Disease

Chief Complaint:

My neck hurts and I have a tingling pain sensation going down my right arm.

History:

Patient is a 68 year-old male with history of neck pain that has been worsening over the last two years. Recently he has experienced some numbness and a painful tingling sensation in his right arm going down to his thumb. No other symptoms or pertinent medical history.

Review of Systems, Physical Exam and Tests:

Review of systems is negative except for the neck pain and sensations in his right arm described above. No history of acute injury to neck or arm.

• Physical exam is normal except for neurological exam of the right upper extremity, which reveals slight decrease to sensation in the thumb and forefinger region of the hand in the C6 nerve root distribution. No evidence of weakness in the muscles of the arm or hand.
• MRI scan of the neck shows degenerative changes of the C5-6 disc with lateral protrusion of disc material. No other abnormalities noted.
• The patient is referred to a pain specialist for evaluation and treatment. Based on the above findings, the pain physician performs a cervical transforaminal injection at C5-6.

Documentation Tips

• Note: To fully describe this patient’s condition with ICD-9 codes, it is necessary to code the degenerative changes
• Note: M50.1 describes cervical disc disorders. The 5th character differentiates various regions of the cervical spine (high cervical C2-3 and C3-4; mid-cervical C4-5, C5-6, and C6-7; cervicothoracic C7-T1 and the associated radiculopathies at each level).

Comparison of Current ICD-9 Code and Illustrative ICD-10 Codes