Necessary support for the documentation of Spinal Enthesopathy , and Inflammatory Spondylopathy

JoseMiguel.RuizJoseMiguel.Ruiz
in Clinical & Coding
Hello I CDI in outpatient setting and:
I have a question regarding, which would be the appropriate support , for that  a physician document, in the assessment plan the following diagnoses,   taking into account that both  belong to HCC 40.The diagnoses are :

1. Spinal Enthesopathy
2. Inflamatory Spondylopathy
My second question is: if only with the radio-logical findings found in a CT of the spine as they are : Hypertrophy of Ligamentum Flavum , and Facet Arthropathy are sufficient support to make a query to the physician, for document the diagnoses named above .?
Thank you

Comments

  • JoseMiguel.RuizJoseMiguel.Ruiz

    Hello I am  CDI in outpatient setting and:
    I have a question regarding, which would be the appropriate support , for that  a physician document, in the assessment plan the following diagnoses,   taking into account that both  belong to HCC 40.The diagnoses are :

    1. Spinal Enthesopathy
    2. Inflamatory Spondylopathy
    My second question is: if only with the radio-logical findings found in a CT of the spine as they are : Hypertrophy of Ligamentum Flavum , and Facet Arthropathy are sufficient support to make a query to the physician, for document the diagnoses named above .?
    Thank you

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    JoseMiguel.Ruiz said:
    Hello I CDI in outpatient setting and:
    I have a question regarding, which would be the appropriate support , for that  a physician document, in the assessment plan the following diagnoses,   taking into account that both  belong to HCC 40.The diagnoses are :

    1. Spinal Enthesopathy
    2. Inflamatory Spondylopathy
    My second question is: if only with the radio-logical findings found in a CT of the spine as they are : Hypertrophy of Ligamentum Flavum , and Facet Arthropathy are sufficient support to make a query to the physician, for document the diagnoses named above .?
    Thank you


    I'd code precisely what is documented:

    1.  M46.00 = disorder of ligamentous or muscular attachments of spine

    2. M46.90 = Unspecified Inflammatory Spondylopathy


    I may not understand total context of the question.   But, the documentation is imprecise, and hence, so are the codes for the stated documentation.  Both are vague conditions...IF there is clinical support for a specific condition, it would be appropriate to query for something more specific.  In the coding index,  one is instructed to 'see, Arthritis, Spine' for the term Facet Arthropathy' and to 'see also' Spondylopathy, inflammatory" for the same term.  Both of these are, again, vague conditions, yielding unspecified codes. 

    Paul Evans, RHIA, CCDS

  • JoseMiguel.RuizJoseMiguel.Ruiz
    Hello Paul , May be , that  I did not performed my question correctly.
    My question is the following:
    Has enough support to document in an assessment the diagnoses of:
    Spinal Enthesopathy ,based only  in the incidental finding of a CT Scan of the spine , that say Hypertrophy of ligamentum Flavum , and degenerative Changes of the spine ? When the Spinal Enthesopathy is associated with autoimmune conditions ? and therefore belong to HCC 40
    The same Happen with the Inflammatory Spondylopathy only based in the radiological finding Facet Atropathy has support for to be documented ?
    Please answer me.
    Thank you .
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