Orthopedic Coding Alert

Question: The orthopedist performs a level-two evaluation and management (E/M) service for an established patient with spondylopathy. The notes state “post-long ligament ossified.” Can you make any sense of that note?

Washington, DC Subscriber

Answer: While it would always be best to check with the performing provider, this diagnosis will likely come from the M48.8X- (Other specified spondylopathies) code set.

Explanation: The ICD-10 entry for M48.8X- includes the description: “Ossification of posterior longitudinal ligament.” Based on the provider’s notes, this sounds like the right code set.

You’ll still need more info, however, before choosing the correct ICD-10 code for your 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) encounter.

Do this: Check with the provider to see if you should be using the M48.8X- code set. Also, ask him about the anatomy of the spondylosis. Then, choose the best ICD-10 code from the following to append to 99212:

• M48.8X1 — Other specified spondylopathies, occipito-atlanto-axial region
• M48.8X2 — … cervical region
• M48.8X3 — … cervicothoracic region
• M48.8X4 — … thoracic region
• M48.8X5 — … thoracolumbar region
• M48.8X6 — … lumbar region
• M48.8X7 — … lumbosacral region
• M48.8X8 — … sacral and sacrococcygeal region
• M48.8X9 — … site unspecified.