Spinal stenosis is a condition that causes abnormal narrowing in the spinal canal resulting in low back pain as well as pain in the legs. The right ICD-10 codes have to be used for reporting this procedure on medical claims.

1. www.outsourcestrategies.com 1-800-670-2809
An Overview of
SPINAL STENOSIS
and Reporting It Using
ICD- 10 Codes
The right ICD-10 codes have to be
used for reporting Spinal stenosis
procedure on medical claims.
8596 E. 101st Street,
Suite H Tulsa, OK
74133
(800) 670 2809 outsourcestrategies.com
2018
OUTSOURCE STRATEGIES INTERNATIONAL

2. www.outsourcestrategies.com 1-800-670-2809
Spinal stenosis is a condition that causes abnormal narrowing in the spinal
canal, which limits the amount of space available for the spinal cord and
nerves. As spinal stenosis becomes more severe, there is compression or
squeezing of the spinal cord and its nerves. This spinal condition can occur
anywhere in the spinal canal, but it is most common in the cervical and
lumbar spine. One of the most common reasons to develop spinal stenosis is
degenerative arthritis or bony and soft tissue changes that result from
ageing. The condition is most commonly seen in patients above the age of
50 years and becomes progressively more severe with increased age.
However, not everyone develops spinal stenosis as they become older.
People who have a family history of spinal stenosis or other spinal or back
problems are at an increased risk of developing this condition due to this
genetic trait. Also, heavy laborers or athletes (who regularly expose their
lower back to a great extent) are at an increased risk to develop spinal
stenosis. It may also occur in people with certain connective tissue diseases
such as ankylosing spondylitis. Quick and effective diagnosis of the root
causes and symptoms of spinal stenosis is important for healthcare providers
to provide proper treatment. Accurate documentation is crucial to ensure
appropriate care and medical coding outsourcing is an ideal option for
physicians to streamline their documentation process.
What Are the Common Symptoms of Spinal Stenosis?
Spinal stenosis is most commonly caused by wear-and-tear changes in the
spine related to osteoarthritis. Some of the other causes of this spinal
disorder may include herniated disks, thickened ligaments, overgrowth of
bone, tumors, and spinal injuries. In severe cases of spinal stenosis,
physicians may recommend surgery to create additional space for the spinal
cord or nerves. The symptoms of this condition may depend on where the

3. www.outsourcestrategies.com 1-800-670-2809
stenosis occurs in the spinal column and it can vary from patient to patient,
ranging in severity from minor to crippling.
The location and severity of the condition may determine the type of
symptoms you may experience. In some cases, people with spinal stenosis
may not experience any specific symptoms. Others may experience some
common symptoms which may include –
• Neck pain
• Pain, numbness, tingling, or cramping in the arms, foot or leg
• Weakness in a hand, arm, foot or leg
• Problems with walking and balance
• Tingling, numbness, or pain that radiates from the lower back into
the buttocks and legs
• Hot or cold feelings in the legs
• Lower back pain while standing or walking
• Weakness along the path of the nerve being compressed
• Bowel or bladder dysfunction (urinary urgency and incontinence, in
severe cases)
How Is Spinal Stenosis Diagnosed and Documented?
For those experiencing symptoms of spinal stenosis, physicians will begin the
diagnosis by enquiring about the initial signs and symptoms, evaluating
previous medical history, performing a detailed physical examination and
observing patient body movements. Physicians may conduct several
diagnostic imaging tests to confirm a suspected diagnosis of this spinal
disorder. These diagnostic imaging tests include –
• X-ray, MRI scan or CT scan to view images of the spine
• Electromyelogram to check the health of spinal nerves
• Bone scans to look for damage or growths in the spine

4. www.outsourcestrategies.com 1-800-670-2809
Treatment for this spinal condition mainly focuses on understanding the risk
factors, reducing symptoms and relieving severe pain. The first-line
treatment will begin non-surgical modalities such as physical therapy
exercises, epidural steroid injections, electrical nerve stimulation and non-
steroidal anti-inflammatory medications. In most cases, it can be treated
without surgery. Physicians who provide specialized treatment to the
patients are reimbursed for their services. Accurately diagnosing the
condition and submitting proper clinical documentation helps in promoting
error-free billing practices. A professional medical coding company can
help physicians with their medical billing tasks. ICD-10 codes for diagnosing
spinal stenosis include –
M48.0 - Spinal stenosis
• M48.00 - Spinal stenosis, site unspecified
• M48.01 - Spinal stenosis, occipito-atlanto-axial region
• M48.02 - Spinal stenosis, cervical region
• M48.03 - Spinal stenosis, cervicothoracic region
• M48.04 - Spinal stenosis, thoracic region
• M48.05 - Spinal stenosis, thoracolumbar region
M48.06 - Spinal stenosis, lumbar region
• M48.061 - Spinal stenosis, lumbar region, without neurogenic
claudication
• M48.062 Spinal stenosis, lumbar region, with neurogenic
claudication
• M48.07 Spinal stenosis, lumbar region, lumbosacral region
• M48.08 Spinal stenosis, lumbar region, sacral and sacrococcygeal
region

5. www.outsourcestrategies.com 1-800-670-2809
Spinal stenosis can lead to gradual but steady loss of strength in the legs.
The severe pain caused by this condition can be quite disabling and affect
your day-to-day life. However, there is no cure for this condition as it most
commonly occurs due to degenerative arthritis that occurs with regular
ageing. However, you can take several important steps to help limit the
severity of symptoms. Maintaining a healthy body weight and doing regular
exercises (flexing, stretching and strengthening exercises) could help in this
regard. Patients should try to modify their physical activities and take care
not to get engaged in any type of activities that can trigger or worsen pain
and disability such as lifting heavy objects or walking long distances.
Practicing good body posture and proper body mechanics can help prevent
this spinal condition to a great extent.