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Neurosurgery Coding Alert

Neurosurgery Coding:

Use 1 Code to Represent Several Spinal Nerve Cyst Types

Question: Encounter notes indicate that the surgeon treated a patient with “cyst, lumb nerve root.” When searching the ICD-10-CM code book, I’m unable to locate a matching diagnosis code. Could you recommend a code, or explain what the surgeon’s note means?

Louisiana Subscriber

Answer: Your surgeon’s note almost certainly means the patient has a cyst on their lumbar nerve root. You’ll report G96.191 (Perineural cyst) for this patient’s cyst. If you look in the notes beneath G96.191, you’ll see that lumbar nerve root cyst is an alternate term for perineural cyst.

More on this Dx: When a patient has a cyst on a spinal nerve root, ICD-10-CM wants you to use G96.191 almost exclusively. In addition to lumbar nerve root cyst, here are the other alternate terms you should code with G96.191:

  • Cervical nerve root cyst
  • Sacral nerve root cyst
  • Tarlov cyst
  • Thoracic nerve root cyst.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC