Neurosurgery Coding Alert

Always know underlying cause for the kyphosis.

When your neurosurgeon diagnoses a patient with kyphosis, this means that the patient’s spine excessively curves forward, typically in the thoracic segments. Kyphosis is also known as roundback or Kelso’s hunchback. To properly report kyphosis in your practice, you must know numerous details including the underlying cause of the kyphosis.

Read on to make sure you understand how to submit clean kyphosis claims.

Identify Underlying Cause of Kyphosis

Question 1: Do you need to know the underlying cause of the kyphosis?

Answer 1: Yes. When submitting a diagnosis of kyphosis, you must make sure you know the underlying cause for the 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 radiation exposure
• Other medical conditions such as tuberculosis of the spine can cause a structural deformity and result in kyphosis, which is called a Gibbus deformity. “While this deformity is not commonly seen in the U.S. because of a low prevalence of TB, patients who have emigrated from countries where TB infection is endemic may present with this deformity here,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

Kyphosis Develops Due to Past Laminectomy? Do This

Question 2: The neurosurgeon documented kyphosis in a patient who had undergone a laminectomy in the past. How should I report this diagnosis?

Answer 2: For kyphosis that develops as a sequence to laminectomy procedure, you should report M96.3 (Postlaminectomy kyphosis).

Observe Correct Dx Code for Postural Kyphosis

Question 3: The adolescent patient has a hump at the top of her spine, a forward positioning of the head, discomfort after prolonged sitting and standing, and fatigue. The surgeon uses the patient’s history, a physical exam, and X-rays to diagnose the patient with postural kyphosis of the cervicothoracic region. Which ICD-10 code should we report for this condition?

Answer 3: You should report M40.03 (Postural kyphosis, cervicothoracic region) for this condition.

Don’t miss: Your other postural kyphosis options include the following codes:

• M40.00 (Postural kyphosis, site unspecified)
• M40.03 (Postural kyphosis, cervicothoracic region)
• M40.04 (Postural kyphosis, thoracic region)
• M40.05 (Postural kyphosis, thoracolumbar region).

Rely on This Code for Postradiation Kyphosis

Question 4: The surgeon documents that the patient has postradiation kyphosis caused by exposure to radiation. What code should I report for this condition?

Answer 4: You should report M96.2 (Postradiation kyphosis) for kyphosis that occurs after exposure to radiation.

Don’t miss: Postradiation kyphosis may result in difficulty breathing, fatigue, mild back pain, a rounded appearance of the back, tenderness, and stiffness in the spine.

See Code Options for Scheuermann’s Kyphosis

Question 5: Is there a “developmental” type of kyphosis and, if so, how would we report this condition?

Answer 5: Yes. Scheuermann’s kyphosis, which is a form of juvenile osteochondrosis, is the most classic form of hyperkyphosis and is the result of wedged vertebrae that develop during adolescence. In this condition, the vertebral bodies wedge forward. Normal vertebrae are rectangular-shaped and stacked on top of one another like building blocks, with a soft cushion between each one. If the front of the vertebrae wedges closer together in a triangular shape, the spine starts to curve forward more than normal.

Scheuermann’s kyphosis is a developmental condition, meaning that it occurs during the patient’s growth, and the cause for this condition is not precisely known.

“Scheuermann’s kyphosis affects younger people, causing an exaggerated forward posture. This is in contrast to aging-related kyphosis that sometime affects the elderly,” Przybylski explains.

You should choose the appropriate code for Scheuermann’s kyphosis depending upon the site. Your options are as follows:

• M42.00 (Juvenile osteochondrosis of spine, site unspecified)
• M42.01 (… occipito-atlanto-axial region)
• M42.02 (… cervical region)
• M42.03 (… cervicothoracic region)
• M42.04 (… thoracic region)
• M42.05 (… thoracolumbar region)
• M42.06 (… lumbar region)
• M42.07 (… lumbosacral region)
• M42.08 (… sacral and sacrococcygeal region)
• M42.09 (… multiple sites in spine).