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Use spinal anatomy as a basis for ICD-9-CM, ICD-10-CM coding

JustCoding News: Outpatient, March 21, 2012

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A knowledge of spinal anatomy provides the foundation necessary to assign codes both before and after the switch to ICD-10-CM.

"It's important for a coder to understand all of these individual segments of the vertebrae because these details are necessary for accurate coding in both diagnoses and procedures," says Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services in Orlando, FL.
Spinal column

The spine is essentially a stack of bones (known as vertebrae) that run down the posterior of the torso from the brainstem to the tailbone. The spinal column is ¬broken into five separate areas, based on location from the top of the spine to the bottom:

  • Cervical, known as C1-C7
  • Thoracic, known as T1-T12
  • Lumbar, known as L1-L5
  • Sacral, known as S1-S5
  • Coccyx, known as CX

The first cervical vertebra, usually known as C1, is also called the atlas. C2, the second cervical vertebra, is also known as the axis. "The good news is these are the only two vertebrae that have alternate names," says Safian.

Thoracic vertebrae make up the middle segment of the vertebral column, between the cervical vertebrae and the lumbar vertebrae. They increase in size moving down the spine, the upper vertebrae being much smaller than those in the lower part of the region. They have facets on the sides of the bodies for articulation with the heads of the ribs, and facets on the transverse processes of all, except the eleventh and twelfth, for articulation with the tubercles of the ribs.

The lumbar vertebrae are located between the thoracic vertebrae and the sacrum. The lumbar vertebrae are the largest vertebrae in the body and lack facets

The sacral vertebrae, or sacrum, start out as five separate bones at birth. By the time an individual reaches his or her mid-20s, the bones fuse into one bony section. After the bones fuse, the S1-S5 designation refers to the location on the single bone, says Safian.
Similar to the sacrum, the coccyx also fuses into one bone as a person ages; it starts out as three to five individual bones at birth.

Vertebral body
Each vertebra includes a vertebral body that surrounds the spinal cord to protect it in the front. The spinous process and the pedicle protect the spinal cord in the back. The pedicles are short stout processes that attach to the superior part of the vertebral body on each side. These extend posteriorly to meet the laminae, which are broad flat plates of bone. The pedicles also overlap the laminae of the vertebrae below.

The articular processes arise from the junctions of the pedicles and laminae. These bony projections have a small smooth surface known as a facet. Each vertebra includes four articular processes, two upper and two lower, that comprise the facet joints.

Coders also need to understand the difference between an interspace and a segment, says Kim Pollock, RN, MBA, CPC, consultant with KarenZupko & Associates, Inc., in Chicago. A vertebral segment represents a single complete vertebral bone with its associated articular processes and laminae.

Although the bones of the vertebral column are stacked on top of each other, they don't actually rest on each other. The vertebral interspace is the non-bony compartment between two adjacent vertebral bodies that contains the intervertebral disc which includes the nucleus pulposus, annulus fibrosus, and two cartilagenous endplates.

"Think of the segment as two bones and the space between," says Pollock.

Coding for congenital conditions
Spinal conditions can be congenital, pathologic, or traumatic, and can affect the vertebrae, spinal cord, muscles, nerves, discs, or a combination of the parts of the spine.

Congenital anomalies of the spine may be simple (no spinal deformity) or complex (severe spinal deformity, cor pulmonale, or paraplegia), Safian says. The most common congenital spinal deformities include hyperlordosis, kyphosis, and scoliosis. In ICD-9-CM, coders would use the same code to report all three conditions, 754.2 (certain congenital musculoskeletal deformities of the spine).

Not surprisingly, ICD-10-CM contains more detailed codes for reporting spinal conditions. Congenital conditions, such as kyphosis, are not only divided out into separate code categories, each with different specific details about the location of the deformity. For congenital kyphosis, coders will chose from:

  • Q76.411, congenital kyphosis, occipito-atlanto-axial region
  • Q76.412, congenital kyphosis, cervical region
  • Q76.413, congenital kyphosis, cervicothoracic region
  • Q76.414, congenital kyphosis, thoracic region
  • Q76.415, congenital kyphosis, thoracolumbar region
  • Q76.419, congenital kyphosis, unspecified region

Physicians will need to document the specific region involved, something that was unnecessary in ICD-9-CM.

Patients can also acquire all three conditions and coders would look to a different set of ICD-9-CM codes:

  • Kyphosis (737.1-), which is further divided into acquired (postural), due to radiation, postlaminectomy, and other
  • Lordosis (737.2-), which is further divided into acquired, postlaminectomy, other postsurgical, and other
  • Kyphoscoliosis and scoliosis (737.3-), which is further divided into idiopathic, resolving infantile idiopathic, progressive infantile idiopathic, due to radiation, thoracogenic, and other

In ICD-10-CM, when a patient is diagnosed with acquired kyphosis, physicians will need to document whether the kyphosis is postural or secondary, as well as the specific site involved.

Coding for pathologic spinal conditions
Underlying diseases can cause a malfunction of the spine or a component of the spine and lead to a variety of pathologic conditions, Safian says. Examples of pathologic spinal conditions include rheumatoid arthritis of spine not otherwise specified (720.0) and Paget’s disease (731.0).

Paget’s disease, also called osteitis deformans, is a slowly progressing metabolic bone disease that is divided into two phases: osteoclastic and ostoblastic, Safian says. When coding for Paget’s disease, coders have two choices:

  • 731.0, osteitis deformans without mention of bone tumor
  • 731.1, osteitis deformans in diseases classified elsewhere

Note that code 731.1 includes a note directing coders to first coding the underlying disease.\

In ICD-10-CM, Paget’s disease has its own series of codes (M88-) which specifies the site of the disease, including the specific bone involved and laterality. For example, coders can choose from three codes for Paget’s disease of the shoulder:

  • M88.811, osteitis deformans of right shoulder
  • M88.812, osteitis deformans of left shoulder
  • M88.819, osteitis deformans of unspecified shoulder

Coding for spinal stenosis
Spinal stenosis is another common pathologic spinal condition. Spinal stenosis is often an age related condition, Safian says. However, patients who suffer a spinal injury or who are born with narrow canal syndrome may seek treatment at a younger age.

In spinal stenosis, narrowing of the nerve cavities (spinal canal and intervertebral foramen) causes pressure of spinal cord, cauda equina, and/or nerve roots. As a result, patients experience severe pain radiating down the extremities, numbness, cramping, and weakness.
When coding for spinal stenosis in ICD-9-CM, coders must know the site of the stenosis:

  • 723.0, spinal stenosis of cervical region
  • 724.0, spinal stenosis, other than cervical
  • 724.00, spinal stenosis, unspecified region
  • 724.01, thoracic region
  • 724.02, lumbar region, without neurogenic claudication
  • 724.03, lumbar region, with neurogenic claudication
  • 724.09, other

In 2011, ICD-9-CM added the distinction for lumbar spinal stenosis with or without neurogenic claudication, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and Coding for HCPro, Inc., in Danvers, MA. However, ICD-10-CM does not include that distinction.

In ICD-10-CM, specific codes identify when the stenosis spans contiguous levels. For example, ICD-10-CM code M48.03 is for stenosis, cervicothoracic, McCall says. In ICD-9-CM, coders would assign separate codes for cervical and thoracic. In ICD-9-CM lumbosacral is in the Alphabetical index but is assigned to the lumbar stenosis code. ICD-10-CM includes a specific code for lumbosacral stenosis—M48.07.

Coding for traumatic spinal injuries
Traumatic injuries to the spine include traumatic fractures (805–806 series), herniated discs (722 series), and whiplash (847.0). When coding for a traumatic fracture in ICD-9-CM, coders must know:

  • Which bone was fractured
  • Whether the fracture is open or closed
  • Which specific segment of the bone was fractured
  • How the patient was injured
  • Where the patient was when injured
  • Whether the spinal cord was injured

The codes for traumatic fractures of the spine are divided into two series—without mention of spinal cord injury (805) and with spinal cord injury (806). All of the codes in the 806 series require a fifth digit for added specificity. Codes 805.0 (cervical, closed) and 805.1 (cervical, open) also require a fifth digit subclassification to identify the specific cervical vertebra involved.

For fractures of the cervical vertebrae using ICD-10-CM, coders won’t need to add an additional character to specify which cervical vertebra is involved. In ICD-10-CM, that information is included in the code description. For a nondisplaced posterior arch fracture of first cervical vertebra, coders would report S12.031 [plus a seventh character].

Traumatic fractures of lumbar vertebra fall under category S32.0- in ICD-10-CM. For these specific fractures, physicians will need to document the specific type of fracture, such as a wedge compression fracture, stable burst fracture, unstable burst fracture, or other fracture.

Codes in category S32.0 also cover fractures of the neural arch, spinous process, transverse process, vertebra, and vertebral arch. Coders should also code first any associated spinal cord and spinal nerve injury (S34-), according to the note.

For all codes in this subsection, coders will need to add a seventh character to specify the encounter, so for an initial encounter, coders would add ‘A’ as the seventh character. Without the seventh character, the code is invalid.

E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.



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