Spine¶

This term can refer to a bulge or a herniation; make sure to pick the correct injury if this is the diagnosis as the severity and healing time for a bulge and herniation are different

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Back Brace for Lumbar Spine Soft Tissue Injury¶

· These are a few different codes that can be used to account for a lumbar support brace

o 2W35X1Z – Application of splint-thoracolumbar spine

o 2W35X3Z.BA- Immobilization of Back using Brace- lumbosacral corset

o 2W35X3Z.DA- Immobilization of Back using Brace- other thoracolumbar or lumbosacral spinal brace

· The system does assess these treatment similarly; however, we recommend you review the system Medical Library text and cross reference this with your medical records to determine the code that best describes the brace used

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Bulging Disc¶

Also Known As

· Disc Protrusion

· Minor/Mild Herniation

· Annular Tear/Fissure

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Compression or Burst Fracture¶

· A compression and a burst fracture are different types of vertebrae fractures

· In the system, it is not necessary to know the type of fracture involved; therefore, compression, burst or any other type of spine fracture is entered as a 'vertebrae fracture' to the affected level of the spine and indication whether the fracture is open or closed

· Freeform search on keywords 'vertebrae fracture'

· Further refine the search by entering the spine level such as, L3 or C2 and whether the fracture is open or closed

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Desiccated Disc or Dehydrated Disc¶

Use of these terms to describe a disc condition generally implies that it is degenerative as opposed to trauma induced; discretion may be required to determine the injury, as it depends on what injury is accepted as being related to the accident

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Discectomy¶

· The system provides 2 types

· To enter a discectomy where surgical excision of the disc is performed, freeform search on 'discectomy' and look for treatment codes described as "Excision of Vertebral Disc"

· This is for a traditional, open form of Discectomy

- The root codes are 0RB3/0RB5 for cervical, 0RB9/0RBB for thoracic and 0SB2/0SB4 for lumbar

· 'Excision or destruction (microdiscectomy, percutaneous discectomy or that by laser) of Vertebral Disc'

· These are the less invasive forms of discectomy which are performed by arthroscopic techniques

· The root codes are 0R53/0R55 for cervical, 0R59/0R5B for thoracic and 0S52/0SB4 for lumbar

· The Medical Library assists in explaining the procedure for the microdiscectomy, endoscopic discectomy and percutaneous discectomy as well as the excision of the disc

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Fusion (Arthrodesis) { #Fusion(Arthrodesis\ }¶

· Also known as Arthrodesis

· To enter a fusion in the system, freeform search on “fusion ” and spine level (example: fusion lumbar or fusion l4-5 spine)

· The freeform search will return several different fusion codes: anterior, posterior and lateral transverse, as well as a generic code

· The Medical Library describes the different techniques ; if it is unclear what the fusion procedure involves it is suggested that you use the appropriate G (generic) code

· Fusion codes in the system include the use of hardware and bone grafts ; no separate coding is needed to account for hardware or bone grafts unless it is harvested from the patient.

· Hardware includes items such as screws, pins, rods and metal cages (also called fusion cages)

· Genetically Produced Bone Protein - a protein that stimulates bone cells and helps the body produce more bone, may be referred to as BMP or rhBMP-2

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Harvested Bone Grafts (Autograft)¶

· If the bone graft is harvested from the patient, then the excision of the bone for the graft is coded as a separate procedure

· The iliac crest is the most common site for bone harvest; the operative report should be read to determine where the bone was harvested.

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Herniated Disc¶

Also Known As

· HNP (Herniated Nucleus Pulpous)

· Ruptured Disc

· Prolapsed Disc

· Extruded Disc

· Slipped Disc

· Annular Tear/Fissure

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Hyperextension and Hyperflexion Injury¶

This injury description can refer to soft tissue neck and back sprain/strains (cervical, thoracic and lumbar sprain/strain), but it can also refer to a spine injury such as a bulge, HNP, fracture or dislocation

If a chiropractor diagnoses a dislocation or subluxation of the spine it is entered in the system as:

· Chiropractic diagnosed subluxation/dislocation

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IDET (Intradiscal Electrothermal Therapy)¶

Is used to treat minor herniations
IDET can be found by a freeform search using IDET or use the medical codes as follows:

BR10YZZ.1 Cervical

** BR17YZZ.1 Thoracic**

** BR19YZZ.1 - Lumbar**

IDET is also sometimes referred to as Annular Denervation , Electrothermal Surgery and Intradiscal Electrothermal Annuloplasty (may see these terms in op reports)

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Laminectomy, laminotomty, foraminotomy and hemilaminectomy¶

· These are forms of decompressive surgery

· If there is an instance where a laminotomy or lamiectomy is done in conjunction with a foraminotomy then enter the code twice to account for each procedure ; a pop-up message will appear to verify the code entered is not a duplicate

· The medical root code in the system for the above treatments is 00JU0ZZ

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Lumbosacral sprain/strain¶

· A lumbosacral sprain/strain is an injury specific to the lumbar and sacral (sacrum) areas of the spine

· The medical code for lumbosacral sprain/strain is S33.8XXA.A

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Manipulation of Spine under Anesthesia¶

· Two types of codes are available

· 9WB1XLZ.1E - Adjustment/manipulation under general anesthesia - cervical spine

· 9WB1XLZ.AF - Adjustment/manipulation under general anesthesia - thoracolumbar spine

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Myelogram and CT Scan¶

· A myelogram is a type of x-ray study of the spine and spinal canal that involves the injection of a dye or contrast material

· A CT scan often follows the study. It provides detailed images of the spine that assist in determining a diagnosis

· When a myelogram and CT scan are done, both procedures should be entered

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Nucleoplasty¶

· Is a form of percutaneous discectomy

· Use the treatment codes described as "Excision or destruction (microdiscectomy, percutaneous discectomy or that by laser) of Vertebral Disc"; the root codes are 0R53/0R55 for cervical, 0R59/0R5B for thoracic and 0S52/0SB4 for lumbar

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Pars defect/defect in pars interarticularis¶

· This is entered in the system as Spondylolysis

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Piriformis Syndrome¶

· Piriformis Syndrome is a term used to describe pain, tingling and/or numbness in the buttock(s) and along the sciatic nerve when the piriformis muscle irritates or compresses the sciatic nerve

· The piriformis muscle is one of the deep muscles of the buttock. It runs from the sacrum to the outer hip bone and aids in external rotation of the hip. The piriformis muscle is close to the sciatic nerve, which is the largest nerve in the body and is formed from the lumbar and sacral nerve roots of the spine. The sciatic nerve passes behind the hip joint and runs down the leg/thigh. It usually passes underneath the piriformis muscle, but in some people the sciatic nerve actually passes or travels through the piriformis muscle

· Currently the system does not have a code for Piriformis Syndrome. If Piriformis Syndrome is accident related and needs to be included in the evaluation of the claim then it will need to be priced outside of the system

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Pre-existing Conditions¶

** Spine Pre-existing codes:**

1. ** Spondylosis (arthritis) M47.81**

2. ** Spondylolysis M43.07**

Spondylolisthesis M43.17
Pre-existing Disc Lesions M5
Spinal Stenosis M48

**6. ** Degenerative Disc Disease cervical/thoracic & lumbar (DDD) M50.30/M51.3

· Note: Pre-existing Disc Lesion is used for any previously documented disc problem (bulge or HNP) that was aggravated by the accident

· The system will assume a neck or back sprain/strain if a Pre-existing Condition is entered with o related spine injury

- When Free Form Medical Search is done on the root codes above make sure to select the Option Type as Pre-exisitng

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Radiculitis (Spinal Complication) { #Radiculitis(Spinal_Complication\ }¶

· Radiculopathy and radiculitis in the system are interchangeable

· Radiculopathy describes any disease of nerve roots and radiculitis is the inflammation of the spinal nerve roots

· Radiculitis can be a complication of an injury to the spine, or be a symptom associated with the aggravation of a pre-existing condition of the spine

· A diagnosis of cervical radiculopathy would be entered as radiculitis

· Radiculitis in relation to spinal injuries affects the arms and legs ; generally if cervical radiculitis is diagnosed it is due to a cervical spine injury and pain will appear in one or both arms; lumbar and thoracic radiculitis is due to a thoracic or lumbar spine injury and pain will be in one or both legs

· True radiculitis can only be diagnosed by needle EMG ; this should be confirmed and the diagnosis of radiculitis or radiculopathy verified before entering the complication in the system

· The needle EMG is done to the arm or leg ; to locate the code search on the upper extremity (arm) or the lower extremity (leg) - not the region of the spine injured; the test is found under Diagnostic Procedures category

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Radiofrequency Lesioning (RFL)¶

· Is a procedure used to treat neck and back pain

· Procedure is also known as thermocoagulation and can Freeform search on this word

· It is also sometimes referred to as radiofrequency ablation (another term you may see in medical reports)

· Freeform search on ‘radiofrequency lesioning’ or medical root code 0151 (cervical), 0158 (thoracic), or 015B (lumbar)

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Sciatica¶

· The specific code for sciatica is non-selectable in the system

· Since sciatica does cause referred pain in the leg(s), it is sometimes referred to as radiculopathy, particularly if there is a disc injury

· Each case will need to be evaluated on an individual basis in order to determine if a diagnosis of Sciatica can/should be entered in the system as radiculitis

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SI Joint Dysfunction¶

· This is pain in the sacroiliac joint

· There is currently no code in the system for SI Joint Dysfunction; however, if there was an injury to the sacroiliac joint which caused the pain then the injury to the sacroiliac joint should be entered

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Traction for Spine Fractures¶

· The spinal traction used to treat spine fractures or dislocations utilizes a halo device or skull tongs; codes for traction related to spine injures are: 0NH0, 2W65X0Z & 2W65XZZ

· Don't confuse the use of a soft cervical collar with a rigid cervical collar, Minerva jacket, halo brace or other cervical brace.

· The soft cervical collar is used in the treatment of soft tissue neck and back sprain/strain injuries (whiplash injury) and the others are used in the treatment of more serious injuries such as a spinal fracture or dislocation

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Trapezius Sprain¶

· The trapezius muscle runs from the base of the neck down to the shoulder blade and upper back

· Frequently, a trapezius sprain/strain is diagnosed in conjunction with a cervical sprain/strain

o It may only be necessary to enter the cervical sprain/strain since trapezius is part of the neck

· Each case should be assessed on its own merits along with a complete review of the medical records in order to determine the injury

· If a trapezius sprain is diagnosed, it is entered in the system as 'shoulder-sprain/strain-teres minor or other muscle/tendon'

· The root code is S46.012 /S46.011 and the code selection will depend on the severity of the sprain/strain

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Spinal Cord Nerve Root Injury¶

· Spinal nerve roots may be injured by being stretched, impinged, compressed, entrapped or avulsed

· The injury is usually the result of a vertebral articular facet may compress nerve roots

· In a degenerative spine, even a whiplash trauma can cause irritation

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¶

Neck/Back Sprain/Strain Medical Codes¶

Cervical¶

S13.4XXA.G Cervical Strain/Sprain

8E0KXY7.GP GP Emergency Room for Cervical

F07J7ZZ.1E Physical Therapy for Cervical

F07J6ZZ.E Assisting Exercise for Cervical

9WB1XLZ.E Chiropractic Treatment for Cervical

Thoracic¶

S23.3XXA.G Thoracic Strain/Sprain

8E0KXY7.GP Emergency Room for Thoracic

F07K7ZZ.1F Physical Therapy for Thoracic

F07K6ZZ.F Assisting Exercise for Thoracic

9WB2XLZ.A Chiropractic Treatment for Thoracic

Lumbar¶

S33.5XXA.G Lumbar Strain/Sprain

8E0KXY7.GP Emergency Room for Lumbar

F07K7ZZ.1F Physical Therapy for Lumbar

F07K6ZZ.F Assisting Exercise for Lumbar

9WB2XLZ.A Chiropractic Treatment for Lumbar

General Practioner/ Treating Specialist Codes¶

8E0KXY7.GP GP Visits for Cervical, Thoracic, and/or Lumbar

8E0KXY7.TS TS Visits for Cervical, Thoracic, and/or Lumbar

Remember to include the Emergency Room visit when entering number of GP visits.

Osteopath is considered a Medical Doctor

COMPLICATIONS¶

R51.W0 Persistent headaches due to whiplash, unknown duration

R51.W1 Persistent headaches due to whiplash, up to 1 month

R51.W2 Persistent headaches due to whiplash, up to 2 months

R51.W3 Persistent headaches due to whiplash, up to 3 months

R51.W4 Persistent headaches due to whiplash, up to 4 months

R51.W5 Persistent headaches due to whiplash, up to 5 months

R51.W6 Persistent headaches due to whiplash, up to 6 months

R51.W7 Persistent headaches due to whiplash, more than 6 months

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