QUESTION: How will coding for congenital spinal conditions change when we move to ICD-10-CM?
ANSWER: Congenital anomalies of the spine may be documented as 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 code 754.2 (certain congenital musculoskeletal deformities of the spine) to denote any of these three conditions.
As expected, ICD-10-CM includes more detailed descriptions for reporting spinal conditions. Congenital kyphosis, for example, requires additional characters 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
Congenital lordosis (Q76.42-) has a similar added level of specificity with regard to the region affected. Therefore, when coding from ICD-10-CM, coders will need to identify the specific region involved from the physician documentation, something currently not required for ICD-9-CM coding.
Editor’s Note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, Fla., answered this question.
This answer was provided based on limited information that was submitted to JustCoding.com. 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 A. Leppert, CPC, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.
