Orthopedic Coding Alert
Get Details Before Choosing Other Spondylopathy Dx
Particulars are vital on this ‘general’ code set. With a pretty generic descriptor, you might think that the codes included in the M48.- (Other spondylopathies) family would be catch-all codes. if anything, the reverse is true. Why? M48.- contains eight different “other” spondylopathy codes. You’ll have to know how far to extend each of these codes — including whether or not you need to use a 7th character. So, these codes can get confusing. To stave off any potential coding headaches, check out this rundown of all the M48.- codes, and how to match the patient with the correct diagnosis code. ‘Foot Drop’ Could Indicate Spinal Stenosis The first code in the family is spinal stenosis, which you’ll report with the M48.0- (Spinal stenosis) codes. According to Johns Hopkins Medicine, the disease might not have symptoms in the early stages. “In most people, symptoms develop gradually over time. Symptoms may include: Report spinal stenosis with M48.0- (Spinal stenosis) codes. 5th character: Almost all of the codes in M48.0- extend to the 5th character. Use this guide to the 5th character options: 6th character option: There is one code in M48.0- that requires you to code to the 6th character. When reporting M48.06- (Spinal stenosis, lumbar region), you’ll have to choose between these two six-character codes: Ankylosing Hyperostosis Involves Upper Back Pain When a patient reports with ankylosing hyperostosis, you’ll report a code from the M48.1- (Ankylosing hyperostosis [Forestier]) set. According to The Arthritis Foundation, symptoms of this condition include: 5th character: As with M48.0- codes, use the 5th characters 0 (Site unspecified) through 8 (Sacral and sacrococcygeal region) when choosing an M48.1- code. Another spondylopathy that a patient might report with is kissing spine, which you’d report with M48.2- (Kissing spine) codes. According to the National Institutes of Health (NIH) “symptoms include back pain with midline distribution that worsens during extension, is relieved during flexion and is exaggerated upon finger pressure at the level of interest.” 5th character: As with M48.0- codes, use the 5th characters 0 through 8 when choosing an M48.2- code. When a patient reports with traumatic spondylopathy, you’ll choose a code from the M48.3- (Traumatic spondylopathy) set. According to the American College of Rheumatology (ACR) low back pain is the most common symptom of traumatic spondylopathy. “Some spondyloarthropathies may affect the hands, feet, arms, or legs. Patients may have pain, fatigue or stiffness that is continuous or comes and goes,” the ACR states. 5th character: As with M48.0- codes, use the 5th characters 0 through 8 when choosing an M48.3- code. These Codes Get a 7th Character There are a pair of M48.- diagnoses that will test your coding abilities a bit. They extend to the 7th character, and require a 6th-character placeholder in order to code correctly. The first condition is fatigue fracture of vertebra. Report the condition with M48.4- (Fatigue fracture of vertebra) codes. Symptoms of fatigue fracture include back pain, a loss in height, and a bent-forward posture. 5th character: As with M48.0- codes, use the 5th characters 0 through 8 when choosing an M48.4- code. 6th character: Use a placeholder X for the 6th character. 7th character: Use 7th character to specify the encounter and stage of the injury. According to ICD-10, you’ll choose from these codes for the 7th character: Example: So if this was an initial encounter for a patient that suffered a fatigue fracture in the sacral region, you’d report M48.48XA (Fatigue fracture of vertebra, sacral and sacrococcygeal region, initial encounter for fracture). You’ll need to employ similar coding strategies for collapsed vertebra, not elsewhere classified: report this condition with M48.5- (Collapsed vertebra, not elsewhere classified). 5th character: As with M48.0- codes, use the 5th characters 0 through 8 when choosing an M48.5- code. 6th character: Use a placeholder X for the 6th character. 7th character: Use the 7th character to specify the encounter and stage of the injury (A through S). Less Specific Spondylopathies Call for These Codes If the spondylopathies aren’t specifically named for the patient, you still have options. One is reporting M48.8X- (Other specified spondylopathies) for other specified spondylopathies. In these diagnosis codes, the 5th character is the X placeholder, and the 6th character specifies the region of the injury (O through 8). Example: So let’s say the physician treats a patient with a specified spondylopathy in the cervicothoracic region. You’ll report M48.8X3 (Other specified spondylopathies, cervicothoracic region) to represent the condition. Last resort: If all else fails and you cannot get a more specific spondylopathy diagnosis, report M48.9 (Spondylopathy, unspecified).
Orthopedic Coding Alert
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