Cervical disc disorder at C4-C5 level with radiculopathy

This code signifies a degenerative or structural abnormality of the intervertebral disc located between the fourth and fifth cervical vertebrae (C4-C5), which is causing nerve root compression or irritation. The radiculopathy manifests as neurological symptoms such as pain, numbness, tingling, or weakness radiating into the upper extremity.

Apply this code when documentation explicitly states a cervical disc disorder at the C4-C5 level, accompanied by signs or symptoms of radiculopathy. This is commonly seen in patients presenting with cervical spondylosis, herniated disc, or disc protrusion affecting the C5 nerve root. Supporting documentation should include imaging reports (e.g., MRI) confirming disc pathology at C4-C5 and clinical notes detailing radicular symptoms.

• Ensure the documentation specifies the exact cervical level (C4-C5) and the presence of radiculopathy.
• Do not use this code for disc disorders without radiculopathy; instead, refer to codes in the M50.2- series.
• Consider sequencing this code as a primary diagnosis if it is the main reason for the encounter, or as a secondary diagnosis if it's a co-morbidity impacting treatment.