As promised in my last blog post, I am going to show you what’s up in ICD-10 when it comes to documentation and coding for spine diagnoses that can end up being treated surgically by an orthopedic surgeon or neurosurgeon, but may be seen by many other primary care physicians along the way. The family of diagnoses I am going to cover briefly are: herniated nucleus pulposus (commonly called a ruptured disc), spinal stenosis and pathologic vertebral fracture.
Disc herniation or degeneration, spinal stenosis
Diagnosis coding and documentation of disc herniation (also known as displacement), disc degeneration and spinal stenosis are not that much different for ICD-10. It is simply a variation on the theme I have been repeating all along, especially for musculoskeletal system codes: There are more codes mainly because there are unique codes for anatomic sites not specified in ICD-9. Sometimes there is more clinical detail as well.
For disc displacement coding, in addition to anatomic site detail there is the optional ability to code associated radiculopathy, if present. This is often documented but cannot be coded in ICD-9 because the same non-specific ICD-9 code is all that is available whether or not there is documented neuritis or radiculitis. Since the associated pain is the tipping point that sends a patient to surgery, this critical indicator of the seriousness of the condition and the likely increased use of resources can now be captured in the data.
In the case of disc degeneration and spinal stenosis, codes in ICD-10 contain the same modest improvements to anatomic site detail. Below are lumbar disc displacement, degeneration and spinal stenosis examples. There are unique codes of this sort for each spinal region.
722.10 Displacement of lumbar intervertebral disc without myelopathy
Is replaced by
M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
M51.26 Other intervertebral disc displacement, lumbar region
M51.27 Other intervertebral disc displacement, lumbosacral region
722.52 Degeneration of lumbar or lumbosacral intervertebral disc
Is replaced by
M51.36 Other intervertebral disc degeneration, lumbar region
M51.37 Other intervertebral disc degeneration, lumbosacral region
724.02 Spinal stenosis, lumbar region, without neurogenic claudication
Is replaced by
M48.06 Spinal stenosis, lumbar region
M48.07 Spinal stenosis, lumbosacral region
Note that there are additional codes specifying the area where the lower two spinal regions meet, as in the lumbar spinal stenosis example above.
As you can see, the documentation requirements for using these codes are nothing onerous. If a patient is diagnosed with one of these conditions, it is standard practice to document the region where the condition occurs. No additional documentation is needed other than the spinal region and the word stenosis or degeneration or displacement.
Non-traumatic vertebral fractures
There are only two ICD-9 codes for non-traumatic vertebral fractures: One for all pathologic fractures of the vertebra, and the other for all stress fractures of “other bone” that includes the vertebra among many other possible sites -- an excellent example of a garbage code. In ICD-10 there are 20 codes. Depending on the area of the classification, they specify either a secondary cause or the spinal region. If the specific cause is known, then the code specifies vertebra and not the spinal level. If the specific cause is not known, then the code specifies the spinal region.
Since spinal region is documented as a matter of course, and there is an unspecified option for the cause, documentation and coding for these new choices is no big deal. If you have established the cause, then you can document it and it can be coded; if you haven’t, you can’t and it can’t. The specific causes available as unique codes are listed below. Collapsed vertebra NEC is considered the unspecified choice.
Cause/type of non-traumatic vertebra fracture
- Age-related osteoporosis
- Other osteoporosis
- Neoplastic disease
- Other disease
- Stress/fatigue fracture
If the cause is not known, then Collapsed vertebra NEC is the code to look for, and of course you will be able to specify the spinal region. Below are the replacement codes for pathologic fracture of vertebra. Codes that specify fracture by cause are listed first followed by lumbar spine examples of codes that specify region but not cause. Stress fracture codes use the term fatigue fracture in the code description, but documenting stress fracture is equally acceptable.
Cause is known
733.13 Pathologic fracture of vertebrae
Is replaced by
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M84.58XA Pathological fracture in neoplastic disease, vertebrae, initial encounter for fracture
M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture
Cause is not known (examples from lumbar region)
M48.56XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture
M48.46XA Fatigue fracture of vertebra, lumbar region, initial encounter for fracture
Rhonda Butler is a senior clinical research analyst with 3M Health Information Systems. She is responsible for the development and maintenance of the ICD-10 Procedure Coding System since 2003 under contract to CMS, and for the development and maintenance of the ICD-10 General Equivalence Mappings (GEMs) and Reimbursement Mappings under contract to CMS and the CDC. She leads the 3M test project to convert the MS-DRGs to ICD-10 for CMS, and is on the team to convert 3M APR-DRGs to ICD-10. Rhonda also writes for the 3M Health Information Systems blog.Rhonda Butler is a senior clinical research analyst with 3M Health Information Systems. She is responsible for the development and maintenance of the ICD-10 Procedure Coding System since 2003 under contract to CMS, and for the development and maintenance of the ICD-10 General Equivalence Mappings (GEMs) and Reimbursement Mappings under contract to CMS and the CDC. She leads the 3M test project to convert the MS-DRGs to ICD-10 for CMS, and is on the team to convert 3M APR-DRGs to ICD-10. Rhonda also writes for the 3M Health Information Systems blog.