Health Information Management

Q&A: ICD-10-CM coding for traumatic spinal injuries

JustCoding News: Outpatient, September 19, 2012

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QUESTION: How will coding for traumatic spinal injuries change in ICD-10-CM?

ANSWER: Traumatic injuries to the spine include traumatic fractures (ICD-9-CM codes 805–806), herniated discs (ICD-9-CM code 722.x), and whiplash (ICD-9-CM code 847.0). When coding for a traumatic fracture in ICD-9-CM, ­coders must know:
  • Which bone was fractured
  • Whether the fracture was open or closed
  • Which specific segment of the bone was fractured
  • How the patient was injured
  • The location at which the injury took place
  • Whether the spinal cord was injured 
In ICD-9-CM, 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 don't need to add an additional character to specify the cervical vertebra involved. That's because this information is included in the code description. For a nondisplaced posterior arch fracture of first cervical vertebra, coders should report ICD-10-CM S12.031 with a seventh character to indicate encounter.

For a displaced lateral mass fracture of first cervical vertebra, coders would assign S12.040, again with the appropriate seventh character. If a patient suffers a posterior displaced Type II dens fracture of the second cervical vertebra, report code S12.111 with a seventh character.

Traumatic fractures of lumbar vertebrae are included in ICD-10-CM code category S32.0-. For these types of fractures, physicians must 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 must add a seventh character to specify the encounter. For example, add an "A" as the seventh character to denote an initial encounter. Without the seventh character, the code is invalid.

Editor’s note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, Fla., answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, Wis. Email her at
ssafian@embarqmail.com.

This answer was provided based on limited information submitted to
JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC, at
mleppert@hcpro.com, and we’ll do our best to get an answer for you.



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