Orthopedic Coding Alert

Hint: You’ll have more options in 2015 than 724.xx describes. 

Spinal stenosis means the patient presents with compression of the spine. To report the correct code, you should specify where the spinal stenosis is occurring. 

ICD-9-CM Code: Here’s how you report this condition right now:

• 723.0, Spinal stenosis in cervical region
  
• 724.00, Spinal stenosis of unspecified region
  
• 724.01, Spinal stenosis, thoracic region
  
• 724.02, Spinal stenosis, lumbar region, without neurogenic claudication
  
• 724.03, Spinal stenosis, lumbar region, with neurogenic claudication
  
• 724.09, Spinal stenosis of other region.
  

ICD-10-CM Code: Here’s how you should report these codes in the future:

• M48.00, Spinal stenosis, site unspecified
  
• M48.01, Spinal stenosis, occipito-atlanto-axial region
  
• M48.02, Spinal stenosis, cervical region
  
• M48.03, Spinal stenosis, cervicothoracic region
  
• M48.04, Spinal stenosis, thoracic region
  
• M48.05, Spinal stenosis, thoracolumbar region
  
• M48.06, Spinal stenosis, lumbar region
  
• M48.07, Spinal stenosis, lumbosacral region
  
• M48.08, Spinal stenosis, sacral and sacrococcygeal region
  

ICD-10-CM Change: When ICD-10 hits, you will still need to report the spinal stenosis code based on the spinal region. However, you will not need to specify neurogenic claudication. You do have a code for site unspecified, but you should always code to the highest specificity. 

Code 723.00 expands into M48.01, M48.02, and M48.03. 

Code 724.01 expands into M48.04 and M48.05. You can also add M48.03 because it refers to the cervicothoracic region. 

Both 724.02 and 724.03 expand to both M48.06 and M48.07. You could also add M48.05 because this code refers to the thoracolumar region. 

Notice that 724.09 becomes M48.08, meaning you now have a specific code for the sacral and sacrococcygeal region. 

Documentation: The provider may document “caudal stenosis.” Remember, the provider needs to specify the region of the spinal stenosis. 

This is how you will locate your codes in the Alphabetical Index:

Stenosis, stenotic (cicatricial) —see also Stricture

- spinal M48.00
- - cervical region M48.02
- - cervicothoracic region M48.03
- - lumbar region M48.06
- - lumbosacral region M48.07
- - occipito-atlanto-axial region M48.01
- - sacrococcygeal region M48.08
- - thoracic region M48.04
- - thoracolumbar region M48.05

Coding tips: You will find these spinal stenosis codes listed under the M48 (Other spondylopathies) category. Remember, you need to look at your provider’s documentation to determine in what region the spinal stenosis is occurring.