Wiki Help with ICD 10 - pathological and the traumatic

nhenderson

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I need an ICD 10 for a nonunion L5-S1. Here is the hx:

Posterior Fusion of L5-S1 on 5/20/13
Fell 4/30/15
Had 2nd surgery on 11/19/15 for an Anterior lumbar interbody fusion 22558 because of the nonunion to L5-S1.

I can't find an ICD 10 to me its not pathological and the traumatic event was 1.5 years ago. Does Z98.1 say enough?

Thanks for your help
 
If this is a non Union of a traumatic fx then you code the fx and use the 7th character for nonunion in this case you with code two fx codes one for the L5 and one for the S1. It does not matter how long ago the original fx was. If the recent fall was due to the non Union of the original fx then you will code the non Union 7th character. If the recent fall cause a new fx then it is initial.
You may not use Z98.1 if the original fx was due to trauma or injury. The guidelines state that you do not use aftercare Z codes for injury or trauma, you always code the injury code sung the appropriate 7th character.
 
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