Greeting from the SuperCoder Team.
Hope you are keeping good.
We have gone through deeply with the query again, and here are the findings:
Since, the doctor’s finding are ‘suggestive’, it can’t be coded as left lumbosacral radiculopathy or asymmetrical peripheral polyneuropathy and therefore you can code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
Also, the electrodiagnostic study shows evidence of decreased amplitude, which is a finding of this study, clinically decreased amplitude can be in both, peripheral neuropathy and entrapment neuropathy as well. A coding report cannot convert the clinical finding to the diagnosis until unless it is not mentioned by the doctor in the document. Link it is mentioned that “left tarsal tunnel syndrome cannot entirely be excluded”, but it is not included as well, so this also cannot be coded.
Some payer allows to code the diagnosis from the diagnostic test reports, it is suggested to check with your policy and code abnormal finding of electromyogram ICD-10-CM code i.e. R94.131. However, this is also not the definitive diagnosis, so you can request your physician to add an addendum with definitive diagnosis or sign and symptoms to bill with CPT 95912 and 95886.
For California, CPT 95912 and 95886 procedure are commonly performed for the following diagnosis codes/Code ranges:
A52.15, E08.40-E08.43, E09.40-E09.43, E10.40-E10.73, E11.40-E11.43, E13.40-E13.43, G13.0, G56.91-G56.93, G57.91-G57.91, G58.0, G59, G60.0-G60.9, G61.1, G61.82, G62.0-G62.2, G62.81-G62.81, G63, G65.1-G65.2, G90.09, G99.0, M05.511-M05.512, M05.521-M05.522, M05.531-M05.532, M05.541-M05.542, M05.551-M05.552, M05.561-M05.562, M05.571-M05.572, M05.59, M34.83.
Apart from these codes, other related codes also can be coded, just there should be a medical necessity.
On the other hand, it is mentioned in the report: History of left plantar foot numbness and tingling and history of left foot and ankle surgery, hence diagnosis code Z87.898 (Personal history of other specified conditions) and Z98.890 (Other specified postprocedural states) can be used for this conditions respectively, but as a status codes for information and not as a primary diagnosis.
We wish for the best reimbursement.
Hope this helps.
Further queries are most welcome.