Neurosurgery Coding Alert

Hint: The “A” character indicates an initial encounter.

When your neurosurgeon documents a spinal nerve root injury, you must check the medical documentation for pertinent details so that you know which ICD-10-CM code to report. For example, first, you should confirm the exact spinal column area where the neurosurgeon identified the nerve root injury. You should also know the nature of the patient encounter.

Read on to learn more.

Always Check Exact Location of Affected Spinal Regions

When reporting spinal nerve root injuries, your first step should be to confirm the spinal column area location your neurosurgeon identifies and documents as having the injury. You must know which of the following spinal regions the nerve root injury occurred — the cervical, thoracic, lumbar, or sacral spine.

Additionally, you must know the type of encounter to report the correct code.

“Like other diagnostic codes for injuries, the encounters are based on whether this is your first evaluation of the patient with the injury, and second or subsequent encounter, or whether the condition remains but is inactive,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

Region 1: Cervical Spine: The cervical spine begins at the base of the skull (occiput) and contains seven vertebrae and eight pairs of cervical nerves that control the neck, arms, and upper body. Your neurosurgeon will usually refer to the seven cervical vertebrae as C1-C7.

Injuries to this portion of the spine can result in radiating pain in the neck, shoulder, and upper extremities.

When you are reporting injuries to the nerve root of the cervical spine, you have the following choices:

• S14.2XXA (Injury of nerve root of cervical spine, initial encounter)
• S14.2XXD (Injury of nerve root of cervical spine, subsequent encounter)
• S14.2XXS (Injury of nerve root of cervical spine, sequela)

Region 2: Thoracic Spine: The thoracic spine is the midsection of the spine and contains 12 vertebrae (T1-T12) and 12 pairs of ribs and nerves that control the body’s midsection. Because the rib cage stabilizes this portion of the spine, injuries are less common than to the cervical or lumbar spine.

For nerve root injuries of the thoracic spine, rely on these codes:

• S24.2XXA (Injury of nerve root of thoracic spine, initial encounter)
• S24.2XXD (Injury of nerve root of thoracic spine, subsequent encounter)
• S24.2XXS (Injury of nerve root of thoracic spine, sequela)

Region 3: Lumbar Spine: Near the bottom of the spine, its strongest region, is the lumbar spine region. There are five lumbar vertebrae designated L1-L5 and five pairs of lumbar nerves that control movement and sensory function in the lower extremities. The lumbar region carries the bulk of the body’s weight and is a common injury site.

For nerve root injuries of the lumbar spine, turn to the following codes:

• S34.21XA (Injury of nerve root of lumbar spine, initial encounter)
• S34.21XD (Injury of nerve root of lumbar spine, subsequent encounter)
• S34.21XS (Injury of nerve root of lumbar spine, sequela)

Region 4: Sacral Spine: The lowest part of the spine is the sacrum, which includes five bones that are fused together known as S1-S5.

For nerve root injuries of the sacral spine, look to these codes:

• S34.22XA (Injury of nerve root of sacral spine, initial encounter)
• S34.22XD (Injury of nerve root of sacral spine, subsequent encounter)
• S34.22XS (Injury of nerve root of sacral spine, sequela)

Don’t Forget Nerve Plexus Injuries

You also have ICD-10-CM code options for nerve plexus injuries. For example, for an injury to the brachial plexus, initial encounter, you should report S14.3XXA (Injury of brachial plexus, initial encounter). For a subsequent encounter, you would report code S14.3XXD (Injury of brachial plexus, subsequent encounter) and for sequela, you should report S14.3XXS (Injury of brachial plexus, sequela).

For an injury to the lumbosacral plexus, initial encounter, you should report S34.4XXA (Injury of lumbosacral plexus, initial encounter). For a subsequent encounter, you should report S34.4XXD (Injury of lumbosacral plexus, subsequent encounter). For a sequela encounter, you should report S34.4XXS (Injury of lumbosacral plexus, sequela).