Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease of the brain and spinal cord. This chronic disease occurs when the patient’s own immune system targets and attacks the protective covering of nerve fibers called the myelin sheath. The resulting damage leads to a disruption in the transmission of nerve signals throughout the body. “In the kNOW” is going to review the different types of MS and the new codes that became effective in October to capture that specificity.

MS types are predominately characterized by how often a relapse occurs and on the progression of symptoms. For most individuals with MS, the relapsing-remitting type is the most common. They will experience a recurrence of symptoms that can last days, weeks, or even months before improving either partially or fully. The time between relapses is the remission period when the disease is dormant. Those periods may last anywhere from months to years. The newly expanded G35 category code for relapsing-remitting multiple sclerosis is G35.A.

Secondary progressive MS is a progression of the relapsing-remitting MS. With the secondary progressive type, the MS symptoms gradually get worse due to the accumulated nerve damage that has taken place. Relapses may still happen, but remission periods are less apt to occur. The new ICD-10-CM codes for secondary progressive MS are:

G35.C0 Secondary progressive multiple sclerosis, unspecified

G35.C1 Active secondary progressive multiple sclerosis

Secondary progressive multiple sclerosis with evidence of inflammatory disease activity

G35.C2 Non-active secondary progressive multiple sclerosis

Secondary progressive multiple sclerosis without evidence of inflammatory disease activity

The next type of multiple sclerosis to be discussed is primary-progressive. This type of MS begins gradually and continues to worsen without any periods of remission. Primary progressive MS codes differentiate between the conditions that have evidence of inflammatory disease activity and those that do not. The codes are:

G35.B0 Primary progressive multiple sclerosis, unspecified

G35.B1 Active primary progressive multiple sclerosis

Primary progressive multiple sclerosis with evidence of inflammatory disease activity

G35.B2 Non-active primary progressive multiple sclerosis

Primary progressive multiple sclerosis without evidence of inflammatory disease activity

Still, we have an option to code multiple sclerosis that is unspecified by assigning G35.D.

While none of these codes carries a designation of CC or MCC, it is nonetheless, vitally important that coding professionals assign the specificity of MS when it is known. Our codes make it possible for research to identify effective treatment and outcomes. Clinical documentation integrity specialists can assist by educating providers of the need for specificity of the type of MS when known.

Now you are In the kNOW!!

 

About the Author

Dianna Foley, RHIA, CCS, CDIP, CHPS, has 25 years of HIM experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA. Dianna’s an AHIMA-approved ICD-10-CM/PCS trainer, an AHIMA-published author, a participant in AHIMA credential item writing and exam development, and served on the AHIMA Nominating Committee. Dianna has held various HIM positions and is now an independent coding consultant. She previously served as a program director for Medical Coding and HIT. She presents on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator.