Common questions—and the answers
Since the introduction of the International Classification of Diseases, 10th Edition (ICD-10), several questions have been asked about coding for diagnoses as related to acquired (atraumatic) disorders of the spine. This article covers a few of the most common scenarios.
Q: I understand that many spinal conditions have greater anatomic differentiation under ICD-10. Do I really need to use this increased specificity in documentation and diagnosis coding?
A: In ICD-10, more differentiation among the regions of the spine is required for the following conditions:
- spinal stenosis—M48.0
- osteomyelitis and diskitis—M46.2 and M46.3
As shown in Table 1, each area is designated by a different digit. Depending on the particular condition, digits 0 or 9 may convey unspecified or multiple sites. It's important to use the most specific ICD-10 code—and that requires improved clinical documentation. The patient's chart must have detailed and complete documentation so that the correct diagnosis and procedure codes can be assigned.
Coding for disk disorders (M50 and M51) uses different digits, as shown in Table 2.
For example, if a patient is diagnosed with radiculopathy due to a herniated disk at C5-6, the coder can use a disk disorder code that is combined with either radiculopathy or myelopathy. The appropriate code in this case would be M50.12.
Q: I recently heard about notes—"Includes," "Excludes type 1," and "Excludes type 2." What do I really need to know about these terms?
A: "Includes" and "Excludes" notes existed before ICD-10. But ICD-10 divided "Excludes" notes into two types. The ICD-10 book states whether any notes can be found at the top of each category. When using two or more diagnosis codes together, beginning users of ICD-10 should search the ICD-10 book to check any notes.
"Includes" notes document synonyms for the diagnosis heading. For example, the S12 category (fracture of cervical vertebrae and other parts of the neck) includes the following fractures: cervical neural arch, cervical spine, cervical spinous process, cervical transverse process, vertebral arch, and neck. The "Includes" note for category M47 (spondylosis) points out that arthrosis or osteoarthritis of spine and degeneration of facet joints are part of this category.
Type 1 "Excludes" notes indicate that the category code should never be used at the same time as the code listed. It means "not coded here." For example, the ICD-10 code for sciatica (M54.3) has a type 1 excludes note for sciatica due to intervertebral disk disorder (coded as M51.1–) and for sciatica with lumbago (coded as M54.4–). Concerns have been raised about the accuracy of some type 1 excludes notes, and these notes are being reviewed.
Type 2 "Excludes" notes mean "not included here." They indicate that the code does not cover the patient's condition, but recognize that a patient could have both the condition covered by the code and the excluded condition at the same time. Therefore, using both codes could be acceptable. For example, M51 (thoracic, thoracolumbar, lumbosacral disk disorders) has a type 2 excludes note for cervical and cervicothoracic disk disorders (M50). Both codes could be used if the patient has both conditions.
NEC versus NOS
Q: When should Other or Other Specified (NEC) be used, as compared to Unspecified or Not Otherwise Specified (NOS)?
A: Other–NEC is used when information in the medical record provides detail for which a specific code does not exist. A specific disease is documented, but it has no diagnosis code. Unspecified–NOS is used when the documentation in the medical record is insufficient to assign a more specific code. In some cases, not enough information may be available to enable the selection of a more specific code. In other cases, it may reflect inadequate or incomplete documentation by the clinician. The clinician should make every effort to avoid the latter situation.
For example, the diagnosis of undifferentiated spondyloarthritis does not have a specific ICD-10 code. If the documentation supports such a diagnosis, M46.86 (other specified inflammatory spondylopathy lumbar spine) should be used.
Crosswalks to codes
Q: I knew where to find all of the ICD-9 codes. Is there a general rule about where I can find my codes in ICD-10?
A: The number of codes in ICD-10 makes it impossible to create a useable "superbill" or "cheat sheet." But technology can help you find the appropriate code. For example, if you know the ICD-9 code and you have the AAOS Code-X product, you can type the ICD-9 code into Code-X and use the X-refs tab to find, at a minimum, the category for that code in ICD-10.
You can then select the appropriate code. In just a few clicks, Code-X narrows the options from more than 91,000 to 1. It also includes additional practice management tools that make it essential for every practice.
The following suggestions may also be helpful in finding frequently used nontraumatic spine codes in ICD-10:
- Musculoskeletal conditions are located in Chapter 13 (M).
- M40–M43 is the area for deforming dorsopathies, including kyphosis, scoliosis, spondylolysis, and spondylolisthesis.
- M45–M49 includes the spondylopathies, such as osteomyelitis of vertebrae, infection of disks, spondylosis, and spinal stenosis.
- M50–M54 includes other dorsopathies, such as disk disorders, spinal instabilities, radiculopathy, sciatica, lumbago, and low back pain.
- M70–79 includes other soft-tissue disorders, such as spinal synovial cyst.
- M80–M85 includes disorders of bone density and structure.
- M96 includes intraoperative and postprocedural complications and disorders of the musculoskeletal system (not elsewhere classified).
However, not all spinal codes are in Chapter 13. Spinal and vertebral tumors are in Chapter 2 (C and D). Spinal abscesses, cysts, chronic pain, and dural tears are in Chapter 6 (G—nervous system). Codes for fractures and injuries can be found in Chapter 19 (S12–S34.9), as can codes for complications of devices and postoperative wound infections of the spine (T81–T88.9).
Finally, an understanding of the external cause and comorbidity chapters is needed for all patients to help convey the complicated nature of the condition. Unfortunately, the comorbidity chapters are located throughout the ICD-10 book, depending on the patient's condition.
Q: One reason for the drastic increase in the number of codes in ICD-10 is the need to document laterality. When would this apply to the spine?
A: The provider is expected to document whether the condition is on the right or left for sciatica (M54.3), lumbago with sciatica (M54.4), and low back pain and sciatica. For example, code 54.41 (lumbago with sciatica, right side) would be used for a patient diagnosed with low back pain and right-side sciatica.
Q: Under ICD-10, the diagnosis codes may have up to 7 characters and may use an "X" as a placeholder. What would be an example for the spine?
A: In the spine, the "X" may be used as a placeholder with spinal instability, which allows for future expansion of the code category. The base code for spinal instability is M53.2X, with the "X" placeholder in the fifth position. The sixth position would designate the various levels of spinal instability, using the numbers 1–9.
The "X" placeholder may also be used in cases in which the seventh character conveys the phase of treatment. Various letters of the alphabet are used to describe the phase of treatment for fractures. (See "When '7' Is Not a Lucky Number," AAOS Now, November 2014.) The "X" and the 7th character are used for conditions related to pathologic fractures due to osteoporosis (M80), neoplastic (M84), or other conditions (M48).
For example, an 85-year-old patient incurred a vertebral compression fracture when getting up from a chair. The appropriate code to use would be M80.08X (Age-related osteoporosis with current pathological fracture, vertebrae). The 7th character would document the phase of treatment, and the "X" would be necessary as a placeholder in the 6th position because the root code has only characters.
Michael R. Marks, MD, MBA, is an orthopaedic surgeon who consults and teaches on practice management and reimbursement issues. He is the founder of Marks Healthcare Consulting and a senior consultant, ICD-10, and CPT coding educator for KarenZupko & Associates, Inc. Margaret M. Maley, RSN, BSN, is a senior consultant with KarenZupko & Associates, Inc., focusing on CPT and ICD-10 coding education for orthopaedic practices. This article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.