Neurosurgery Coding Alert

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

Your transition to ICD-10 for spinal nerve root injury will not be difficult. You have direct match for the ICD-9 codes. The only challenge you may face is when your physician either documents injuries in multiple spinal regions or when your physician does not specify the region of injury. Learn how you can meet these challenges in ICD-10. 

Spinal Regions Guide You to Correct Code

When you report injury in spinal nerve roots, the first step for you is to confirm where exactly in the spinal column your physician identifies and documents the injury. 

ICD-9 codes: When reporting injury to spinal nerve roots in ICD-9, you confirm the site of injury. For injury in the cervical, thoracic, lumbar, and sacral spinal nerve roots, you report ICD-9 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, you will have a one-to-one match for the ICD-9 codes for spinal nerve roots injury. You will select 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

You Have Direct Match for Plexus Injuries

Like the codes for spinal nerve root injuries, you have a one-to-one match for injury to nerve plexuses too. For injury to brachial plexus, you report ICD-9 code 953.4 (Injury to brachial plexus). This code maps 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 lumboscaral plexus maps to ICD-10 code S34.4XXA (Injury of lumbosacral plexus, initial encounter).

Make Sure the Spinal Regions are Documented

ICD-10 will not offer any choice for reporting when your surgeon does not document the exact site of injury to the spinal nerve roots. ICD-9 has the following 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 

In ICD-10, these two codes map to codes S14.2XXA, S24.2XXA, S34.21XA, S34.22XA, and S34.4XXA.

This means ICD-10 leaves you with no choice if your physician does not document the site of spinal nerve root injury. On the other hand, 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.