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December 17, 2012

Coding for Peripheral Neuropathy
For The Record
Vol. 24 No. 23 P. 25

Peripheral neuropathy involves damage to the peripheral nerves, which send information to and from the brain and spinal cord to other parts of the body. Damage to a peripheral nerve may affect communication between the brain and other body parts and may cause problems with muscle movement and sensation in the arms and legs.

The condition can cause problems to a single peripheral nerve (mononeuropathy), multiple nerves in different areas (multiple mononeuropathy), or many nerves throughout the body (polyneuropathy). Additionally, it may affect sensory, motor, or autonomic nerves.

Peripheral neuropathy may be the result of diabetes, traumatic injuries, infections, metabolic problems, and toxins, with diabetes being the most common cause.

Symptoms of peripheral neuropathy vary depending on the type of nerve affected. Common signs and symptoms include numbness and tingling in feet or hands; burning pain in the arms and legs; sharp, jabbing, or electriclike pain; extreme sensitivity to touch; lack of coordination; muscle weakness or paralysis if motor nerves are affected; and bowel or bladder problems if autonomic nerves are affected.

ICD-9-CM Coding
Mononeuropathy or mononeuritis is classified to ICD-9-CM categories 354 and 355. Additional digits will identify the specific nerve involved as follows:

• 354.0, Carpal tunnel syndrome;

• 354.1, Other lesion of median nerve;

• 354.2, Lesion of ulnar nerve;

• 354.3, Lesion of radial nerve;

• 354.4, Causalgia of upper limb;

• 354.5, Mononeuritis multiplex;

• 354.8, Other mononeuritis of upper limb;

• 354.9, Mononeuritis of upper limb, unspecified;

• 355.0, Lesion of sciatic nerve;

• 355.1, Meralgia paresthetica;

• 355.2, Other lesion of femoral nerve;

• 355.3, Lesion of lateral popliteal nerve;

• 355.4, Lesion of medial popliteal nerve;

• 355.5, Tarsal tunnel syndrome;

• 355.6, Lesion of plantar nerve;

• 355.71, Causalgia of lower limb;

• 355.79, Other mononeuritis of lower limb;

• 355.8, Mononeuritis of lower limb, unspecified; and

• 355.9, Mononeuritis of unspecified site.

Peripheral neuropathy that is not further specified as being caused by an underlying condition is assigned to code 356.9. Autonomic neuropathy not further specified is classified to code 337.9. If either peripheral or autonomic neuropathy is caused by diabetes, then a code from subcategory 250.6 will be sequenced first followed by code 357.2 for polyneuropathy in diabetes or code 337.1 for peripheral autonomic neuropathy.

Diabetic peripheral neuropathy is one of the more serious complications of long-term diabetes. It typically affects patients with type 1 diabetes more frequently than those with type 2 and occurs more often in men. It’s thought to evolve from damage to capillaries in the extremities caused by the long-term effects of poorly controlled or uncontrolled blood glucose. This vascular damage injures the peripheral nerves. Patients describe the pain as burning, tingling, and occasionally stabbing.

If a patient is admitted with a diabetic neuropathy or has neuropathy caused by diabetes, the diabetic code from category 250 must be sequenced as the principal diagnosis followed by the manifestations as secondary diagnoses. Conditions are coded in this manner even though the ICD-9-CM alphabetic index may not indicate dual coding (AHA Coding Clinic for ICD-9-CM, 1991, third quarter, page 8). In other words, the physician must state a cause-and-effect relationship between the manifestation and the diabetes before it can be coded as a diabetic condition.

A patient with diabetes can develop neuropathy that is unrelated to the diabetes. If this is the case, the unspecified diabetes code will be assigned as well as the appropriate code for the neuropathy. Sequencing of the two conditions will depend on the circumstances of admission. However, if the physician establishes a link between the diabetes and the neuropathy, then it will be coded as a diabetic complication. According to Coding Clinic, if the physician documents “diabetes with neuropathy,” then a cause-and-effect relationship has been established, and it can be coded as a diabetic complication (250.6x + 357.2) (AHA Coding Clinic for ICD-9-CM, 2009, second quarter, page 15).

Addressing Neuropathy
It is not possible to cure neuropathy, but several medications have been found to help ease the pain. Among the most common medications are tricyclic antidepressants such as imipramine; serotonin and norepinephrine reuptake inhibitors, including duloxetine (Cymbalta); certain antiseizure medications, including pregabalin (Lyrica), gabapentin (Neurontin), and carbamazepine (Tegretol); lidocaine patches; and ointments such as ArthriCare and Zostrix (both of which are based on the chemical that gives peppers their heat).

Finally, in extreme cases, powerful opioid analgesics such as OxyContin can be helpful, but the addictive aspect of these medications makes them a risky choice. For some patients with diabetic peripheral neuropathy, a physician might apply a transcutaneous electrical nerve stimulation unit or recommend therapies such as biofeedback, acupuncture, hypnosis, meditation, and yoga.

Coding and sequencing for peripheral neuropathy are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.


ICD-10-CM Coding for Peripheral Neuropathy
Coding neuropathy in ICD-10-CM is similar to coding it in ICD-9-CM. Upper-limb mononeuropathies are classified to category G56, and lower-limb mononeuropathies go to category G57, with the additional characters identifying the specific nerve and laterality. Polyneuropathy is classified to categories G60 to G65.

If the neuropathy is caused by diabetes, then only one combination code is assigned to identify both the diabetes and the neuropathy. ICD-10-CM has combination codes in the diabetes section for the following types of diabetic neuropathy: mononeuropathy, polyneuropathy, autonomic (poly)neuropathy, and amyotrophy. For example, type 1 diabetes mellitus with diabetic polyneuropathy is classified to code E10.42, and type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy is assigned to code E10.43.

— AH