April 16, 2013

ICD-10: Documentation for Cervical Spine Injuries

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There are many different types of injuries that can occur to the bone and soft tissues of the cervical spine. In ICD-10-CM, documentation still must provide information on the general type of injury (fracture, dislocation, sprain, etc.), level (C1, C2, C3, etc.), and whether there is any associated spinal cord injury. However, much more detail for each type of injury must be provided to allow assignment of the most specific code possible for acute injuries to the cervical spine.

Cervical Spine Fractures

For most vertebral fractures, there are only two fracture types that have specific codes. All other specified fracture types are reported with an “other specified” code. If the type of vertebral fracture is not specified, an “unspecified” code is assigned. The two specific codes are for traumatic spondylolisthesis, Type III, and other traumatic spondylolisthesis. An exception is traumatic fractures of the C1 and C2 vertebrae. Due to the different bony configurations of these two vertebrae, different types of fractures may occur at these levels.

Specific codes for cervical spine fractures at the C1 (atlas) vertebra include posterior arch fractures (which are the most common type at this level), lateral mass fractures, and burst fractures. Burst fractures are subclassified as stable or unstable. A burst fracture at C1 also may be referred to as Jefferson fracture.

At the C2 (axis) vertebra, one of the most common types of fracture is a traumatic spondylolisthesis, which also may be referred to as a Hangman’s fracture. Traumatic spondylolisthesis refers to a slippage or displacement of the vertebrae from an acute injury, and the severity of the injury can vary significantly. For this reason, traumatic spondylolisthesis is classified as Type I, II, IIA, or III. A Type I spondylolisthesis has minimal (less than 3 mm) displacement and no angulation. Type II spondylolisthesis may have either anterior angulation or disruption of the intervertebral disc. Type IIA injuries have severe angulation without anterior translation (displacement). Type III injuries have severe angulation and severe displacement with unilateral or bilateral facet dislocations.

Another common C2 fracture site is the dens, also referred to as the odontoid process. Dens fractures also are classified by type, with the most common dens fracture being a Type II. A Type II fracture occurs at the base of the dens and is usually transverse. Type I dens fractures are rare and involve an oblique avulsion type of fracture of the tip of the dens. A Type III dens fracture is an unstable fracture that extends into the vertebral body.

Cervical spine fractures are reported with codes from category S12, Fracture of the cervical vertebra and other parts of the neck. There are specific codes for the more common types of fractures of each cervical vertebra. In order to assign the most specific codes at each level, the following information is required:

  • C1 vertebra
    • Burst fracture – documentation should indicate whether it is stable or unstable.
    • Posterior arch fracture
    • Lateral mass fracture
    • Other specified fracture type
    • Unspecified

 

  • C2 vertebra
    • Dens
      • Type II – documentation should indicate whether the dens is nondisplaced or displaced anteriorly or posteriorly.
      • Other type
    • Traumatic spondylolisthesis
      • Type III
      • Other traumatic spondylosisthesis
    • Other specified fracture type
    • Unspecified
  • C3-C7 vertebrae
    • Traumatic spondylolisthesis
      • Type III
      • Other traumatic spondylosisthesis
    • Other specified fracture type
    • Unspecified

Most fracture types are subclassified as displaced or non-displaced. As with all fractures, a seventh character is required to identify the episode of care (initial, subsequent, sequela, etc.). Other details that must be identified include whether the status of the fracture is open or closed during the initial encounter, and for subsequent encounters, whether healing should be documented as routine, delayed, or nonunion. Again, the “open” or “closed” status of the fracture is captured by the seventh character, so an additional code for an open wound is not required; however, spinal cord injuries associated with the fracture are coded separately.

Cervical Spine Dislocation, Subluxation and Sprain

Codes for dislocation and sprains of the joints and ligaments of the neck are found in category S13. This category includes specific codes for traumatic rupture of the disc (S13.0-), subluxation, and dislocation at each interspace (S13.1-), plus sprain of ligaments such as the anterior longitudinal ligament of the cervical spine (S13.4-).

Subluxation and dislocation injuries are reported with different codes, so documentation must identify the interspace (C1-C2, C2-C3, etc.) and whether the injury is a subluxation or dislocation. Subluxation refers to anterior displacement of the upper vertebra in relation to the vertebra below, with the articular surfaces (facets) of the apophyseal joints remaining in contact. The term dislocation is used when the articular facets are no longer in contact at the apophyseal joint and both of the inferior facets of the displaced (upper) vertebra are locked in front of the superior facets of the vertebra below.

All codes in category S13 require a seventh character to identify the episode of care as initial, subsequent or sequela. If the injury is described as an open injury, an additional code is assigned for the open wound. Subluxation or dislocation injuries with spinal cord injury require an additional code for the spinal cord injury.


Spinal Cord Injuries

Injuries to the cervical spine may occur with or without associated spinal cord injury. When there is an associated spinal cord injury, it typically is listed first. Injuries of the spinal cord must be documented as:

  • Concussion/edema – There is bruising, inflammation and/or bleeding at the site of the injury, typically causing temporary loss of function, but as the injury heals, most patients experience full recovery of motor and sensory function.
  • Complete lesion – There is complete loss of function below the level of the injury, which, depending on the level of the injury, may include complete or partial loss of arm function or the need for a ventilator to assist respiratory function.
  • Central cord syndrome – Damage occurs at the center of spinal cord, which results in loss of function of the arms, but some leg movement is left intact.
  • Anterior cord syndrome – The front part of the spinal cord is damaged, which results in impaired temperature and sensory function and/or pain sensation; however, some movement below the level of the injury is typically present, and the ability to move may improve over time.
  • Brown-Sequard Syndrome – One side of the spinal cord is damaged, which results in impaired movement but intact sensation on one side and impaired sensation but intact movement on the opposite side.
  • Other incomplete lesion – Other incomplete lesions include posterior cord syndrome, which is characterized by poor coordination, but intact muscle power and sensation.
  • Unspecified lesion – Codes for unspecified spinal cord lesion would be reported only for cervical spinal cord injuries when no additional information on the specific type of lesion is provided.

Codes for injury to the nerves and spinal cord at the neck are found in category S14. If multiple cervical levels show evidence of spinal cord lesions, the code for the highest level is assigned. So if the patient has an incomplete lesion at C4 and C5 levels, code S14.154, Other incomplete lesion at C4 level of cervical spinal cord.

About the Author

Lauri Gray, RHIT, CPC, has worked in the health information management field for 30 years. She began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Most recently she has worked as a clinical technical editor of coding and reimbursement print and electronic products. She has also taught medical coding at the College of Eastern Utah. Areas of expertise include: ICD-10-CM, ICD-10-PCS, ICD-9-CM diagnosis and procedure coding, physician coding and reimbursement, claims adjudication processes, third-party reimbursement, RBRVS and fee schedule development. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.