Neurology & Pain Management Coding Alert

Question: The neurologist documented kyphosis in a patient who had undergone a laminectomy in the past. How should I report this diagnosis?

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Answer: For kyphosis that develops as a sequence to laminectomy procedure, you should report M96.3 (Postlaminectomy kyphosis).

Make sure you don’t mix up M96.3 with other kyphosis codes. For example, you would report M40.00 (Postural kyphosis, site unspecified) for kyphosis acquired due to wrong posture and M40.1 (Other secondary kyphosis) for kyphosis due to other causes.

Caution: When submitting a diagnosis of kyphosis, you must always know the underlying cause for kyphosis. Some of the common causes of kyphosis include the following:

• Degeneration, such as in degenerative arthritis with disc space collapse;
• Osteoporosis;
• Vertebral fractures;
• Vertebral trauma;
• Acquired due to a persistent bad posture;
• A consequence of surgical procedures in the spine, like a laminectomy or as a consequence of exposure to radiation; and
• Other medical conditions such as tuberculosis of the spine can cause a structural deformity and result in kyphosis. This is called Gibbus deformity.

Also: Kyphosis may occur due to developmental problems. Scheuermann’s kyphosis is the most classic form of hyperkyphosis and is the result of wedged vertebrae that develop during adolescence. This is a developmental condition, and the cause for this condition is not precisely known.

“In circumstances where there is a clear diagnosis responsible for the kyphosis, it is recommended to additionally report the cause of the kyphosis,” says Gregory Przybylski, MD, past chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.