Health Information Management

Tip: Note ICD-10-CM documentation requirements for congenital spinal conditions

APCs Insider, June 1, 2012

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Congenital anomalies of the spine may be simple (e.g., no spinal deformity) or complex (e.g., severe spinal deformity, cor pulmonale, or paraplegia). The most ­common congenital spinal deformities are:

  • Hyperlordosis
  • Kyphosis
  • Scoliosis
In ICD-9-CM, coders report 754.2 (certain congenital musculoskeletal deformities of the spine) to denote all three conditions.
Not surprisingly, ICD-10-CM includes more detailed codes for reporting spinal conditions. For example, congenital conditions, such as kyphosis, are divided into separate code categories based on the specific location of the deformity. In ICD-10-CM, coders must choose from among the following codes for congenital kyphosis:
  • 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 must document the specific region involved, which is not something they currently do in ICD-9-CM.
The tip is adapted from “Compare ICD-9-CM, ICD-10-CM coding for spinal conditions” in the May Briefings on APCs.

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