Transcription → Structured Coding Report
Source: Outpatient consult audio • Duration: 9m12s • Transcribed: 2025-10-30
Transcript Snippet
Patient is a 46-year-old male presenting with neck pain radiating to the left arm with numbness in the thumb and index finger. Symptoms aggravated by extension. MRI shows C5/6 disc herniation contacting the cord with foraminal narrowing. Plan: trial of conservative therapy; if progressive deficit, consider decompression.
Suggested ICD Codes
| Code | Description | Confidence |
|---|---|---|
| M50.12 | Cervical disc disorder with radiculopathy | 0.92 |
| G55.1 | Nerve root compression syndrome | 0.85 |
| M54.2 | Cervicalgia | 0.74 |
Suggested RPL (SAMA/MDCM) Codes
| Code | Description | PMB Note |
|---|---|---|
| 5763 / 5764 | Anterior cervical discectomy (level-dependent) | PMB may apply if cord/root compression (see G95.2 / G55.1) |
| 0970 | Anterior plating | By indication |
| 5770 | Microscope-assisted surgery | Technique modifier |
Documentation Prompts
- Record baseline neurological deficit and objective weakness tests
- Attach MRI report images with level and laterality clearly indicated
- Note conservative therapy duration/failure and red flags (myelopathy)
- Confirm patient scheme option and PMB protocol requirements
Generated by MedCascade • Sample data • Not medical advice