ICD Code M54.11

ICD code M5411 is used to identify a medical condition known as radiculopathy in the occipito-atlanto-axial region. This condition involves nerve root issues that occur in the upper cervical spine, specifically around the base of the skull and the first two cervical vertebrae. Patients with this condition may experience symptoms such as pain, tingling, or weakness in the areas served by the affected nerves. Proper diagnosis and coding of this condition are crucial for healthcare providers to ensure accurate treatment plans and appropriate billing processes.

When to use the ICD code for Radiculopathy, occipito-atlanto-axial region:

1. Presence of Neck Pain
- Patient reports localized pain in the neck region.

2. Radiating Pain
- Pain radiates from the neck into the upper extremities, potentially following a dermatomal pattern.

3. Numbness or Tingling
- Patient experiences numbness or tingling sensations in the arms or hands.

4. Muscle Weakness
- Weakness in the upper extremities, particularly in specific muscle groups innervated by affected nerve roots.

5. Reflex Changes
- Diminished or absent reflexes in the upper extremities, indicating nerve root involvement.

6. Positive Neurological Examination Findings
- Findings such as positive Spurling's test or other neurological assessments indicating nerve root compression.

7. Imaging Results
- MRI or CT scans show evidence of cervical spine abnormalities, such as herniated discs or foraminal stenosis, correlating with clinical symptoms.

8. Duration of Symptoms
- Symptoms persist for a duration that suggests a chronic condition, typically lasting more than six weeks.

9. Impact on Daily Activities
- Symptoms significantly interfere with the patient's daily activities or quality of life.

10. Exclusion of Other Conditions
- Other potential causes of symptoms have been ruled out through clinical evaluation and diagnostic testing.

For the ICD code M54.11, which pertains to radiculopathy in the occipito-atlanto-axial region, the relevant CPT codes that may be applicable for treatment include:

1. CPT 99201-99205: Evaluation and Management (E/M) services for new patients, which may be necessary for initial assessment and diagnosis.

2. CPT 99211-99215: E/M services for established patients, used for follow-up visits and ongoing management.

3. CPT 20552: Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s), which may be used if trigger point injections are part of the treatment plan.

4. CPT 20610: Arthrocentesis, aspiration, and/or injection into a major joint or bursa, which might be relevant if joint injections are indicated.

5. CPT 62321: Injection(s), including anesthetic, steroid, and/or other substance(s); epidural or subarachnoid, cervical or thoracic, which may be used for pain management.

6. CPT 64479: Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level, which is often used for nerve root pain.

7. CPT 97012: Application of a modality to 1 or more areas; traction, mechanical, which may be part of physical therapy treatment.

8. CPT 97110: Therapeutic exercises to develop strength and endurance, range of motion, and flexibility, which could be part of a rehabilitation program.

9. CPT 97140: Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), which may be used in physical therapy.

10. CPT 99241-99245: Consultation services, which might be necessary if a specialist's opinion is required.

These CPT codes are examples of procedures and services that might be utilized in the treatment of radiculopathy in the occipito-atlanto-axial region, as indicated by ICD code M54.11. The specific codes used will depend on the individual patient's treatment plan and the healthcare provider's clinical judgment.

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