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Chiropractic Coding & Compliance Alert

You Be the Coder:

How to Code Subluxation of the Lumbar and Sacral Spine

Published on Thu Nov 12, 2015 Print Friendly and PDF PDF

Question: What diagnosis codes can we submit for a patient who presents with a subluxation of the lumbar and sacral spine with degeneration of disc(s) in the lumbar region?

Mississippi Subscriber

Answer: You can report M99.03 (Segmental and somatic dysfunction of lumbar region) as the primary diagnosis, followed by a secondary diagnosis of M51.36 (Other intervertebral disc degeneration, lumbar region) and M51.37 (Other intervertebral disc degeneration, lumbosacral region). These come under the category of “Other dorsopathies.”

In addition, you submit code M99.84 (Other biomechanical lesions of sacral region). However, note that you must have a neuromuscular complaint as well to report M99.84. Additional ICD-10 codes describing lumbosacral subluxation include Q76.2 (Congenital spondylolisthesis).

Noridian Medicare states, “If you need to document more than four diagnosis codes, as will be the case any time there are more than two regions billed, the additional diagnoses must be present in the medical record.”

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