Neurology & Pain Management Coding Alert

You have no options if your physician does not document the region of injury.

Choosing the best diagnosis for spinal nerve root injury will be simple for most cases under ICD-10 because the current codes have a one-to-one crossover. The tricky part will be in knowing how to select the code when your physician either documents injuries in multiple spinal regions or does not specify the region of injury. Focus on two simple steps to point you toward success. 

Step 1: Verify the Affected Spinal Regions

When you report injury in spinal nerve roots, begin by confirming the exact spinal column area that your physician identifies and documents as having the injury. 

ICD-9 codes: When reporting injury to spinal nerve roots in ICD-9, you confirm the site of injury. For the cervical, thoracic, lumbar, and sacral spinal nerve roots, you report codes 953.0 (Injury to cervical nerve root), 953.1 (Injury to dorsal nerve root), 953.2 (Injury to lumbar nerve root), or 953.3 (Injury to sacral nerve root), respectively. 

ICD-10 options: When ICD-10 is implemented in October 2015, you’ll have a one-to-one match for the ICD-9 codes related to spinal nerve root injury. You’ll choose from the following codes for injury in the cervical, thoracic, lumbar, and sacral spinal nerve roots, respectively:

• S14.2XXA – Injury of nerve root of cervical spine, initial encounter
  
• S24.2XXA – Injury of nerve root of thoracic spine, initial encounter
  
• S34.21XA – Injury of nerve root of lumbar spine, initial encounter
  
• S34.22XA – Injury of nerve root of sacral spine, initial encounter.
  

Plus: Like the codes for spinal nerve root injuries, ICD-10 also will have a one-to-one match for injury to nerve plexuses. For injury to brachial plexus, you currently report ICD-9 code 953.4 (Injury to brachial plexus). This code will map to ICD-10 code S14.3XXA (Injury of brachial plexus, initial encounter). Similarly, the ICD-9 code 953.5 (Injury to lumbosacral plexus) for injury of lumbosacral plexus will map to ICD-10 code S34.4XXA (Injury of lumbosacral plexus, initial encounter).

Step 2: Confirm Spinal Region Documentation

ICD-9 has two options for injuries at multiple regions and when your physician does not document the affected nerve roots:

• 953.8 – Injury to multiple sites of nerve roots and spinal plexus 
  
• 953.9 – Injury to unspecified site of nerve roots and spinal plexus. 
  

Change: ICD-10 will not offer any choice for reporting when your physician does not document the exact site of injury to the spinal nerve roots. Instead, the two current codes map to several options: 

• S14.2XX- (Injury of nerve root of cervical spine, …)  
• S24.2XX- (Injury of nerve root of thoracic spine, …)
• S34.21X- (Injury of nerve root of lumbar spine, …)
• S34.22X- (Injury of nerve root of sacral spine, …) 
• S34.4XX- (Injury of lumbosacral plexus, …). 

Each code includes further designations for initial or subsequent encounter or sequela. The more details you know about the patient’s case, the better you can pinpoint an accurate diagnosis. And, if your physician documents multiple sites of spinal nerve root injury, you can report two or more codes depending upon which spinal nerve roots were injured.