Multiple Sclerosis Documentation Guide
Autoimmune demyelinating disease of the central nervous system.
ICD-10 Codes: G35
Common Symptoms
- Vision changes
- Numbness and tingling
- Fatigue
- Weakness
- Spasticity
- Cognitive difficulties
- Balance problems
Key Documentation Elements
- MS type classification
- EDSS score
- Relapse history and last relapse date
- Current disease-modifying therapy
- MRI findings and lesion burden
- Functional status and disability assessment
Documentation Challenges
- Classifying MS type (relapsing-remitting, secondary progressive, primary progressive)
- Documenting relapse frequency and recovery
- Recording disease-modifying therapy response and monitoring
- Capturing EDSS disability score and functional status
Billing Considerations
- Complex chronic care management for ongoing DMT
- Infusion billing for IV disease-modifying therapies
- Documentation supporting high-complexity E&M visits
- Rehabilitation referral documentation
Frequently Asked Questions
How is multiple sclerosis documented for coding?
MS uses G35 as the primary code. Documentation should include MS type, EDSS score, relapse history, and DMT regimen. Scribeable captures all of these elements from your clinical encounter.
How does Scribeable support MS management documentation?
Scribeable captures disability scores, relapse assessments, DMT monitoring labs, MRI results, and functional status from your encounter to produce comprehensive MS visit documentation.