PMB Realignment & Clinical Validation for Anterior Cervical Discectomy Case
Objective
Apply appropriate downcoding to ensure alignment with PMB eligibility, while retaining clinical integrity of care. This is standard when:
- The primary ICD is not PMB, but clinically supported alternative PMB diagnoses exist.
- The procedure is medically necessary and tied to eligible DTP categories (e.g. myelopathy, spinal stenosis, radiculopathy due to nerve root or cord compression).
Step 1: Primary ICD-10 Review
| Submitted ICDs | Description | PMB Status |
|---|---|---|
| M50.12 / M50.22 | Cervical disc disorder with radiculopathy/myelopathy | Non-PMB |
| G95.2 | Cord compression | PMB |
| G55.1 | Nerve root compression syndromes | PMB |
| M47.12 / M48.02 / M47.22 | Spondylosis, stenosis, instability | PMB |
Step 2: Aligned Downcoding Strategy
| RPL Code | Original ICD | Aligned PMB ICD | Reason for Realignment |
|---|---|---|---|
| 5763 / 5764 | M50.12 / M50.22 | G55.1 | Cervical disc herniation → root compression = radiculopathy |
| 0941 / 0942 | M47.12 / M48.02 | PMB already | No change required |
| 0963 | — | G95.2 | PMB; no change required |
| 0970 | M47.12 | PMB | No change required |
| 5770 | M50.22 | G55.1 | Microscopic decompression = compression syndrome |
| 0730 / 0733 / 0713 | — | G55.1 / G95.2 | PMB; no change required |
| 2831 | — | G55.1 | PMB; no change required |
| 2941 | M47.22 / M48.02 | PMB | No change required |
Final Clinical Coding Table with PMB-Compliant ICD Assignments
| RPL Code | Procedure Description | PMB ICD Used | Justification |
|---|---|---|---|
| 5763 / 5764 | Anterior discectomy | G55.1 | Root decompression for cervical radiculopathy |
| 0963 | Cord decompression | G95.2 | Confirmed cord compression |
| 0941 / 0942 | Interbody fusion | M48.02 | Instability + stenosis |
| 0970 | Anterior plating | M47.12 | Degenerative cervical instability |
| 5770 | Microscope technique | G55.1 | Neural decompression via magnified field |
| 0730 / 0733 / 0713 | Intraoperative neuro-monitoring | G95.2 / G55.1 | Cord/nerve safety support |
| 2831 | Major neurolysis | G55.1 | Root adhesion release |
| 2941 | Osteophyte removal | M47.22 | Root/spinal cord decompression |
Clinical Validation Statement
The revised ICD coding reflects pathologies of spinal cord and nerve root compression (G95.2 / G55.1), which are fully consistent with clinical findings of myeloradiculopathy, spondylotic instability, and compressive cervical disc disease. All listed procedures are medically indicated and aligned to PMB-eligible DTP categories for:
- Neurological dysfunction
- Spinal cord compression syndromes
- Chronic back/neck syndromes with neurological deficit
1. Primary Clinical Diagnosis (PMB-Aligned)
M48.02 – Spinal Stenosis, Cervical Region (Primary ICD-10)
This diagnosis reflects multilevel cervical spinal canal narrowing with associated cord and nerve root compression. It is WHO primary-compliant and PMB-eligible. This forms the basis for decompressive and stabilizing surgical intervention.
2. Supporting Diagnoses (PMB)
- G95.2 – Myelopathy due to compression
- G55.1 – Nerve root compression syndrome
- M47.12 – Cervical spondylosis with myelopathy
3. Surgical Coding Bundle (RPL Codes)
| RPL Code | Description | ICD-10 Code(s) | PMB Status |
|---|---|---|---|
| 5763 / 5764 | Anterior cervical discectomy | M48.02 + G95.2 | PMB |
| 0941 / 0942 | Interbody fusion (1+ levels) | M48.02 / M47.12 | PMB |
| 0970 | Anterior plating | M47.12 | PMB |
| 0963 | Cord decompression | G95.2 | PMB |
| 2941 | Osteophyte removal | M47.22 / M48.02 | PMB |
| 0730 / 0733 / 0713 | Intraoperative neuro-monitoring | G95.2 / G55.1 | PMB |
| 2831 | Major neurolysis | G55.1 | PMB |
| 5770 | Microscope-assisted surgery | G95.2 / M48.02 | PMB |
4. Clinical Justification
Patient presents with progressive myeloradiculopathy confirmed by imaging showing multilevel cervical spinal stenosis (C3–C6) with cord compression. Surgical intervention was medically necessary to decompress neural structures, stabilize the spine, and prevent neurologic deterioration. All procedures performed are clinically and procedurally aligned to PMB-eligible diagnoses as defined in the DTP list under: "Chronic spinal conditions with neurological deficit."
5. Recommendation
Please process all submitted RPL items under PMB protection based on the primary diagnosis (M48.02) and confirmed procedural alignment. This case qualifies for full PMB reimbursement without co-payment.