Crystal's Coder HubTags: icd10 diagnosis documentation pmr procedures
Musculoskeletal (Chapter 13)
- Laterality: Must specify Left, Right, or Bilateral.
- Episode of Care: Initial (A), Subsequent (D), Sequela (S).
- Specificity: “Low back pain” (M54.50) vs “Lumbar radiculopathy” (M54.16).
Neurological (Chapter 6)
- Stroke: Requires combination codes for side and dominance (e.g., I69.351).
- Peripheral Neuropathy: Must link to underlying cause (e.g., Diabetic G62.9 + E11.40).
EMG and Nerve Conduction Studies
CPT Range
Coding Rules
- NCS: Coded by the number of studies, not nerves. One study = one nerve/muscle group tested.
- EMG: Coded by limbs and whether paraspinal muscles were tested.
- 95870: 1 limb
- 95871: 2 limbs
- 95872: 3 limbs
- 95873: 4 limbs + paraspinals
Documentation
- Must document specific muscles/nerve segments tested.
- Must include interpretation and report.
- Modifier -26 (Professional Component) if equipment is owned by facility.
Same Day E/M
You can bill E/M on the same day as EMG if the E/M is significant and separately identifiable. Use Modifier 25 on the E/M code.
Functional Limitations
- Medicare requires G-Codes and Severity Modifiers for outpatient therapy claims (PT/OT/SLP).
- Physicians do not bill G-codes on professional claims but must document the functional limitation to support medical necessity.
Common PM&R Diagnoses
- M54.50: Low back pain, unspecified.
- M25.561: Pain in right knee.
- G89.29: Other chronic pain.
- Z47.1: Aftercare following joint replacement surgery.
Unspecified Codes
Avoid “Unspecified” codes (ending in 9 or 0) whenever possible. They are high-risk for audits. Document laterality and specificity.
00 PM&R Coding MOC Medical Necessity in Rehab
| LAM — Laminectomy - Exploration or decompression of spinal cord through excision or incision into vertebral structures | ||
|---|---|---|
| CPT Codes | Code Description | Code Status |
| 22220 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical | No change |
| 22222 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic | No change |
| 22224 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar | No change |
| 22856 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical | No change |
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar | No change |
| 22861 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | No change |
| 22862 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | No change |
| 22867 | Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level | No change |
| 62287 | Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar | No change |
| 62351 | Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy | No change |
| 62380 | Endoscopic decompression of spinal cord, nerve root(s), including laminectomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interpace, lumbar | No change |
| 63001 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical | No change |
| 63003 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic | No change |
| 63005 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis | No change |
| 63011 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral | No change |
| 63012 | Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) | No change |
| 63015 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical | No change |
| 63016 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic | No change |
| 63017 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar | No change |
| 63020 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical | No change |
| 63030 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar | No change |
| 63035 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each No changeitional interspace, cervical or lumbar (List separately in No changeition to code for primary procedure) | No change |
| 63040 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical | No change |
| 63042 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar | No change |
| 63045 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical | No change |
| 63046 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic | No change |
| 63047 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar | No change |
| 63048 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) | No change |
| 63050 | Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; | No change |
| 63051 | Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed) | No change |
| 63055 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic | No change |
| 63056 | lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc | No change |
| 63064 | Costovertebral approach with decompression of spinal cord or nerve root(s), (eg, herniated intervertebral disc), thoracic; single segment | No change |
| 63075 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace | No change |
| 63077 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace | No change |
| 63081 | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment | No change |
| 63082 | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each No changeitional segment (List separately in No changeition to code for primary procedure) | No change |
| 63085 | Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment | No change |
| 63086 | Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each No changeitional segment (List separately in No changeition to code for primary procedure) | No change |
| 63087 | Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment | No change |
| 63088 | Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each No changeitional segment (List separately in No changeition to code for primary procedure) | No change |
| 63090 | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment | No change |
| 63091 | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each No changeitional segment (List separately in No changeition to code for primary procedure) | No change |
| 63101 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment | No change |
| 63102 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment | No change |
| 63103 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic or lumbar, each No changeitional segment (List separately in No changeition to code for primary procedure) | No change |
| 63170 | Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar | No change |
| 63172 | Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space | No change |
| 63173 | Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space | No change |
| 63180 | Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments | No change |
| 63182 | Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments | No change |
| 63185 | Laminectomy with rhizotomy; 1 or 2 segments | No change |
| 63190 | Laminectomy with rhizotomy; more than 2 segments | No change |
| 63191 | Laminectomy with section of spinal accessory nerve | No change |
| 63197 | Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage, thoracic | No change |
| 63200 | Laminectomy, with release of tethered spinal cord, lumbar | No change |
| 63250 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical | No change |
| 63251 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic | No change |
| 63252 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar | No change |
| 63265 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical | No change |
| 63266 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic | No change |
| 63267 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar | No change |
| 63268 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral | No change |
| 63270 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical | No change |
| 63271 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic | No change |
| 63272 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar | No change |
| 63273 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral | No change |
| 63275 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical | No change |
| 63276 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, thoracic | No change |
| 63277 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar | No change |
| 63278 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, sacral | No change |
| 63280 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical | No change |
| 63281 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, thoracic | No change |
| 63282 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar | No change |
| 63283 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, sacral | No change |
| 63285 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical | No change |
| 63286 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic | No change |
| 63287 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar | No change |
| 63290 | Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level | No change |
| 63709 | Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy | No change |
| 63740 | Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; including laminectomy | No change |
| 0202T | Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine | No change |
| 0219T | Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical | No change |
| 0220T | Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic | No change |
| 0221T | Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar | No change |