Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon performed an office evaluation and management (E/M) service for an established patient with severe neck pain. During the E/M, which included a high level of medical decision making (MDM), the surgeon orders a three-view X-ray of the cervical spine, which reveals a fracture of the first cervical vertebra. How should I report this encounter?

Ohio Subscriber

Answer: The CPT^® coding for this encounter is pretty straightforward; the ICD-10 coding, not so much.

CPT^® coding: On the claim, report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) for the E/M and 72040 (Radiologic examination, spine, cervical; 2 or 3 views) for the X-ray.

ICD-10 coding: You’ll start at S12.0- (Fracture of cervical vertebra and other parts of neck) — but that’s not where you’ll finish.

Go back and check the notes for the following information on the patient’s injury:

• What type of fracture did the surgeon treat? Open, closed, displaced, nondisplaced, stable burst, unstable burst. etc.
• What treatment stage was the encounter for? Initial, subsequent, sequala, etc.

Then, you’ll choose one of the following codes, depending on the answers to the questions above:

• S12.000- (Unspecified displaced fracture of first cervical vertebra)
• S12.001- (Unspecified nondisplaced fracture of first cervical vertebra)
• S12.01X- (Stable burst fracture of first cervical vertebra)
• S12.02X- (Unstable burst fracture of first cervical vertebra)
• S12.030- (Displaced posterior arch fracture of first cervical vertebra)
• S12.031- (Nondisplaced posterior arch fracture of first cervical vertebra)
• S12.040- (Displaced lateral mass fracture of first cervical vertebra)
• S12.041- (Nondisplaced lateral mass fracture of first cervical vertebra)
• S12.090- (Other displaced fracture of first cervical vertebra)
• S12.091- (Other nondisplaced fracture of first cervical vertebra)

1 more thing: To complete the diagnosis, choose one of the following 7th character options:

• A=initial encounter for closed fracture 
• B=initial encounter for open fracture
• D=subsequent encounter for fracture with routine healing
• G=subsequent encounter for fracture with delayed healing
• K=subsequent encounter for fracture with nonunion
• S=sequela.