Understanding Spine-Related Coding

Tune in to this monthly online coding column, facilitated by AHIMA’s coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.


Spine-related coding can be very difficult. And while the discussion is often centered around the procedure portion of the coding, coders face challenges when assigning the diagnosis codes as well.

Whether caused by a degenerative disease process or trauma, most spinal conditions result in significant pain requiring medical and/or surgical treatment. The following list details some conditions that are commonly documented in patient medical records along with a brief definition, per Dorland’s Medical Dictionary.

  • Spondylosis: A term used interchangeably with “osteoarthritis,” indicates ankylosis (stiffening) of a vertebral joint. Also indicates degenerative spinal changes due to osteoarthritis.
  • Spondylolisthesis: Forward displacement of one vertebra over another.
  • Spinal Stenosis: Term for the narrowing of the vertebral canal, nerve root canals, or intervertebral foramina of the lumbar spine that is caused by encroachment of bone.
  • Myelopathy: Term for various functional disturbances or pathological changes in the spinal cord; often refers to nonspecific lesions, in contrast to the inflammatory lesions associated with myelitis.
  • Radiculopathy: Disease of the nerve roots, due to such things as inflammation or impingement from a tumor or bony spur.
  • Disc Herniation/Bulging Disc: Protrusion of te nucleus pulposus or anulus fibrosus of an intervertebral disc, which may impinge on nerve roots.

The American Hospital Association’s Coding Clinic has recently published some clarifying articles on spinal diagnosis coding. These Coding Clinic updates are very timely and should resolve many questions related to spinal diagnosis coding.

The second quarter 2018 issue of Coding Clinic addressed the question: “What is the correct code assignment for degenerative changes of the cervical spine when documented on an outpatient radiology report? Are degenerative changes considered incidental and related to the normal aging process? Would the findings of narrowing and spurring be coded or should the final interpretation of degenerative changes be coded?”

Their answer was as follows:

Assign code M47.812, Spondylosis without myelopathy or radiculopathy, cervical region, for the final interpretation of degenerative changes of the cervical spine. ICD-10-CM’s Index to Diseases under the main term “Degeneration” and subterms “changes, spine or vertebra” directs “see Spondylosis.” The subterm “joint disease” directs “see Osteoarthritis.” The index entry for Osteoarthritis of the spine also points to spondylosis.

The third quarter 2018 issue of Coding Clinic addressed the question: “Would code M51.16 be assigned for lumbar spondylolisthesis with radiculopathy? If not, what is the appropriate code assignment for a diagnosis of L4-L5 spondylolisthesis with radiculopathy?”

Their answer was as follows:

Assign codes M43.16, Spondylolisthesis, lumbar region, and M54.16, Radiculopathy, lumbar spine, for spondylolisthesis with radiculopathy. Code M51.16, Intervertebral disc disorders with radiculopathy, lumbar region, is not the appropriate code assignment. Spondylolisthesis is not an intervertebral disc disorder. In spondylolisthesis, the bony vertebra slips. A disc disorder typically involves herniation or displacement of the interior disc.

**Note spondylolisthesis is not an intervertebral disc disorder. It is not the same as a herniated disc.

The same issue of Coding Clinic also addressed the question: “The provider’s documentation describes cervical stenosis with spinal cord and nerve root compression. What is the proper code assignment for cervical stenosis with C4-C7 spinal cord and nerve root compression?”

Their answer was as follows:

In this case, the patient has cervical spinal stenosis (C4-C7) with both radiculopathy (nerve root compression) and myelopathy (spinal cord compression). Assign codes M48.02, Spinal stenosis, cervical region, M54.12, Radiculopathy, cervical region, and G99.2, Myelopathy in diseases classified elsewhere.

The third quarter 2018 issue also addressed the following questions:

  • “What is the code assignment for stenosis of the cervical spine at C3-C6 with myelopathy?”
  • “A patient presents with cervical spinal stenosis (C5- C6) and degenerative disc disease with myelopathy and radiculopathy that is surgically treated via laminectomy. What is the code assignment for cervical spinal stenosis (C5-C6) and degenerative disc disease with myelopathy and radiculopathy (cord and nerve root compression)?”

 

Elena Miller is the director of coding audit and education at a healthcare system.

2 Comments

  1. very useful info

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