2021 ICD-10-CM Diagnosis Code M48.02 Spinal stenosis, cervical region 2016 2017 2018 2019 2020 2021 Billable/Specific Code M48.02 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
The codes for the anterior spinal fusion are 0SG00AJ (L4-L5) and 0SG30AJ (L5-S1). Two codes are also assigned for the posterior spinal fusion, 0SG0071 (L4-L5) and 0SG3071 (L5-S1).
Stenosis, foramen magnum ICD-10-CM M48.02 is grouped within Diagnostic Related Group (s) (MS-DRG v38.0): 551 Medical back problems with mcc 552 Medical back problems without mcc
Osteotomy 22206 Osteotomy of spine, thoracic 22207 … lumbar + 22208 each add’l 22210 … cervical 22212 … thoracic 22214 … lumbar + 22216 each add’l 77.39 Osteotomy, vertebrae 77.29 Osteotomy, vertebrae, wedge 34 Coding for Spinal Procedures AHIMA 2009 Audio Seminar Series 18 Notes/Comments/Questions Arthrodesis Arthrodesis
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M53. 82 - Other specified dorsopathies, cervical region | ICD-10-CM.
There are two different types of spinal stenosis. The type you have depends on where on your spine the condition is. Cervical stenosis is when the neck area of your spine is narrow. Lumbar stenosis is when the lower back area of your spine is narrow.
Cervical spinal stenosis occurs when one or more intervertebral foramina (bony openings where the spinal nerves exit the spinal canal) become narrowed within the neck.
6: Pain in thoracic spine.
M54. 2 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM M54.
Definition. Cervical stenosis is a condition in which the spinal canal is too small for the spinal cord and nerve roots. This can cause damage to the spinal cord, a condition called myelopathy, or pinch nerves as they exit the spinal canal (radiculopathy).
Spinal stenosis is a pinched nerve condition that can cause pain in the back, neck and sometimes the arms and legs. It most commonly affects people between the ages of 50 and 60.
There are three main types: central spinal stenosis, lateral recess stenosis, and foraminal stenosis, each of which can happen in any region of the spine (i.e. cervical, thoracic, or lumbar).
The C8 spinal nerve exits the spinal cord in between the C7 and T1 vertebrae through a small bony opening called the intervertebral foramen. This nerve has a sensory root and a motor root.
Spinal stenosis and foraminal stenosis describe the narrowing of the canals in your spine. Spinal stenosis is the narrowing of the canals through which the spinal cord travels, foraminal stenosis is the narrowing through which the spinal nerves travel before exiting the spine.
Neural foraminal stenosis, or neural foraminal narrowing, is a type of spinal stenosis. It occurs when the small openings between the bones in your spine, called the neural foramina, narrow or tighten.
The two types of spinal stenosis are lumbar stenosis and cervical stenosis. Lumbar spinal stenosis is the more common of the two, but cervical spinal stenosis is often more dangerous since it involves compression of the spinal cord.
Surgical treatment For patients with cervical stenosis with myelopathy, the only effective treatment option is surgery to decompress the spinal cord. One type of this kind of surgery is a posterior cervical laminectomy.
Cervical stenosis is one of the most serious results of this degeneration. Also called cervical spinal stenosis, or simply spinal stenosis, the condition is most common in adults ages 30-50 and affects about twice as many men as women.
Spinal stenosis may rarely involve both cervical and lumbar spines. An alternative surgical strategy used for the treatment of combined cervical and lumbar spinal stenosis is presented. Two cases with symptomatic combined stenosis of the cervical and lumbar spinal canal are described.
Though it is not specifically mentioned, “thoracolumbar” likely only includes T12-L1, and “lumbosacral” probably only refers to the L5-S1 interspace. There is a strange rule for cervical disc disorders indicating that you should code to the most superior level of the disorder.
These spinal disc codes appear to be a bit complex, but with some study and evaluation, the logic used to create them becomes clear. The provider can use the codes to guide proper documentation and the coder then can select the right codes with confidence.
It is already included in the code. Likewise, don’t code sciatica (M54.3-) if you code for lumbar disc with radiculopathy. It would be redundant. On a side note, lumbar radiculopathy (M54.16) might be used if pain is not yet known to be due a disc, but it radiates from the lumbar spine.
The codes for the anterior spinal fusion are 0SG00AJ (L4-L5) and 0SG30AJ (L5-S1) . Two codes are also assigned for the posterior spinal fusion, 0SG0071 (L4-L5) and 0SG3071 (L5-S1) . Codes 0SB20ZZ and 0SB40ZZ are also assigned for the discectomy performed at two different levels of the spine. Lastly, code 0QB20ZZ is assigned for the harvesting of the right iliac crest bone graft.
The implementation of ICD-10-PCS has enhanced the skills of coding professionals as it contains many unique features that provide an opportunity to accurately reflect the complexity of the procedures being performed. The assignment of ICD-9-CM procedure codes for spinal fusions often challenged coding professionals, and this has not changed with the transition to ICD-10-PCS. As with the coding of other complex surgical procedures, coding professionals struggle with identifying which portion of the spinal fusion procedure to code or not to code.
The code for this procedure is 0QB20ZZ, with the body part character (fourth character) being 2 for right pelvic bone. The iliac crest does not have its own distinct body part value in ICD-10-PCS, with the ICD-10-PCS Body Part Key indicating that the pelvic bone is the closest proximal branch.
If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used, the procedure is coded with device value Autologous Tissue Substitute (7)
Qualifier: The qualifier character identifies the column of the spine being fused (anterior or posterior) and if the surgical approach is from the front or back of the body (see Figure 1 below).
As with Examples #1 and #2, the segmental instrumentation is included in the spinal fusion and is not coded separately. The lumbar decompression L4-L5 and L5-S1 bilateral foraminotomies and L3 decompression laminectomy are also considered to be integral to the spinal fusion and not coded separately.
Decompression is the general term to describe removal of the spinal disk, bone, or tissue causing pressure and pain. Often, this is the only procedure performed. Examples include: laminectomy to decompress spinal canal and/or nerve roots (e.g., 63001-63017, 63045-+63048), discectomy to decompress spinal canal and/or nerve roots (e.g., 63020-+63035, 63040-+63044, 63055-+63057), corpectomy (e.g., 63081-+63091), fracture repair (e.g., 22325-+22328), etc.#N#CPT® designates the decompression codes as being per “vertebral segment” or per “interspace.” Decompression occurs at the interspace for discectomy codes (e.g., right L4-L5 interspace). Discectomy is a single, standalone code, such as 63030 Laminotomy (hemilaminectomy), with decompression of nerve root (s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar.#N#But decompression of the spinal canal can be coded per vertebral segment (63001-63017), or per level of foraminotomy (e.g., decompression of the L4 exiting nerve root via partial laminectomy at L4 and partial laminectomy at L5, with foraminotomy at L4-L5, is reported using one code: 63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root [s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar).#N#Discern whether the approach was posterior or anterior to choose the correct code. Table A illustrates commonly used, standalone decompression codes for spine surgery.#N#Table A: Standalone decompression codes for spine surgery
“It seems like coding spine cases is as complicated as doing the surgery,” said a spine surgeon at his first coding training session with me.#N#Spine procedure coding can make even the most confident coder squirm. But spine procedure coding doesn’t have to be difficult. In fact, it’s quite formulaic. Follow these five principles and spine procedure coding will go from scary to simple.