ICD Code M54.12

ICD code M5412 is used to identify and classify the medical condition known as radiculopathy in the cervical region. Radiculopathy refers to a condition where one or more nerves are affected and do not work properly, leading to pain, weakness, numbness, or difficulty controlling specific muscles. In the context of the cervical region, this condition affects the nerves in the neck area, which can cause symptoms to radiate down the arms and into the hands. This code is crucial for healthcare providers to accurately document and communicate the diagnosis for treatment planning and insurance billing purposes.

When to use the ICD code for Radiculopathy, cervical region:

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

2. Radiating Pain
- Pain radiates from the neck down into the shoulder, arm, or hand.

3. Numbness or Tingling
- Patient experiences numbness or tingling sensations in the upper extremities.

4. Muscle Weakness
- Weakness in the muscles of the arm or hand is reported.

5. Reflex Changes
- Diminished or absent reflexes in the upper extremities are observed during examination.

6. Sensory Changes
- Altered sensation (e.g., hypersensitivity or loss of sensation) in the arm or hand.

7. Neurological Examination Findings
- Positive findings on neurological examination indicating nerve root involvement.

8. Imaging Results
- MRI or CT scans show evidence of cervical disc herniation or foraminal stenosis affecting nerve roots.

9. Duration of Symptoms
- Symptoms persist for a specific duration, typically more than a few weeks, indicating chronicity.

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

For the ICD code M5412 (Radiculopathy, cervical region), the relevant CPT codes that may be applicable for treatment include:

1. CPT 99201-99205 - New patient office or other outpatient visit for the evaluation and management of a patient.

2. CPT 99211-99215 - Established patient office or other outpatient visit for the evaluation and management of a patient.

3. CPT 20552 - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).

4. CPT 20553 - Injection(s); single or multiple trigger point(s), 3 or more muscles.

5. CPT 20610 - Arthrocentesis, aspiration, and/or injection into a major joint or bursa.

6. CPT 62321 - Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT).

7. CPT 64479 - Injection(s), anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level.

8. CPT 64483 - Injection(s), anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level.

9. CPT 72141 - Magnetic resonance imaging, spinal canal and contents, cervical; without contrast material.

10. CPT 72156 - Magnetic resonance imaging, spinal canal and contents, cervical; with contrast material(s).

These CPT codes are commonly associated with the evaluation, management, and treatment procedures for conditions related to cervical radiculopathy. It's important for healthcare providers to select the appropriate CPT code based on the specific services rendered and the clinical scenario.

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