Anesthesia Coding Alert

Question: We often see patients who have an arm or leg fracture with an additional diagnosis of "spine - not cleared" or "C-spine - not cleared." The patient is usually in a collar and is undergoing spinal precautions. I know we can't code for possible, probable or similar diagnoses, but is there an appropriate ICD-9 code for possible spine injuries not cleared?

California Subscriber

Answer: Coders have different opinions about whether you should code for "not-cleared" procedures - and it's up to you which camp you choose to follow.
 
Some coders believe that using the collar and taking spinal precautions is more a clinical protocol than a  diagnosis, so they choose not to code for it. Other coders opt for an appropriate E code that describes the source of the trauma (such as a fall or an auto accident) to help clarify the diagnosis picture and explain the use of fiberoptic intubation, a higher physical status (P) modifier, or other factors that contribute to the patient's higher risk status.
 
Coders who do report the possible injury recommend 959.8 (Injury, other and unspecified; other specified sites, including multiple) or 959.09 (Injury of face and neck), along with the appropriate E code, and a code from the V71.x series (the family of codes related to observation of suspected conditions). You might want to report all of these codes (the higher physical status modifier, the appropriate 900.x injury code, and the appropriate code from V71.x) in order to give a complete picture of the case if the physician used fiberoptic intubation. Be sure to submit supporting documentation with the claim.