Full Clinical & Coding Analysis
Case ID: MC-ANL-003 (synthetic) • Discipline: 62 (Neurosurgery) • Date: 2025-10-22
1) Case Overview
- Patient: MC-003 (synthetic), adult
- Presentation: Cervical radiculopathy with progressive left C6 distribution numbness
- Imaging: MRI C5/6 disc protrusion contacting cord with left foraminal narrowing
- Conservative care: NSAIDs, physiotherapy (6 weeks) — partial response
2) ICD Alignment & PMB Review
| Candidate ICD | Description | PMB Relevance | Notes |
|---|---|---|---|
| M50.12 | Cervical disc disorder with radiculopathy | Secondary | Primary complaint matches radiculopathy |
| G55.1 | Nerve root compression syndrome | PMB | Cord/nerve compression evidence supports PMB |
| M48.02 | Cervical spinal stenosis | PMB | Stenosis at C5/6 corroborated by MRI |
3) RPL/NHRPL Bundle Rationalisation (SAMA/MDCM)
| RPL Code | Description | Justification |
|---|---|---|
| 5763 / 5764 | Anterior cervical discectomy (level-dependent) | Radiculopathy from C5/6 protrusion |
| 0963 | Cord decompression | If myelopathy present (defer if not documented) |
| 0970 | Anterior plating | Stability requirement per intra-op assessment |
| 5770 | Microscope-assisted surgery | Technique modifier for decompression |
4) Risk & Rule Checks
- Duplication review: avoid overlap between 5755 and 5763/5764 (choose the more specific set)
- Bundling: ensure neurolysis (2831) not billed separately unless distinct from decompression
- Scheme requirements: pre-authorisation and PMB protocols differ by scheme/option
- Tariffs: coming soon; scheme-specific tariffs vary and are indicative when shown
5) Documentation Completeness
- MRI report with level and laterality
- Neurological examination baseline (motor/sensory/reflex)
- Conservative care timeline and outcomes
- Informed consent records and surgical notes (if performed)
6) Recommended Next Steps
- Confirm PMB eligibility with scheme referencing G55.1/M48.02 where clinically supported
- Obtain pre-authorisation as required; attach imaging and clinical summaries
- Prepare a submission pack (see Submission Report) with itemised RPL list and motivations
Generated by MedCascade • Billing assist only • Sample data • Not medical advice