Neurosurgery Coding Alert

Question: I’m a little unclear on spinal compression fractures. What exactly are they, and how do I spot them in the encounter notes? Further, what are some ICD-10 codes that reflect compression fracture? I’ve not found the term in the ICD-10 book.

New Jersey Subscriber

Answer: Compression fracture typically occurs when one or more bones in the spine weaken and crumple, says Nate Felt, MS, ATC, PTA, CPC, of Utah-based Intermountain Medical Group. Compression fractures can be due to trauma or be caused by a loss of bone mass — osteoporosis — that occurs as a part of aging. “Something as simple as a cough or lifting a heavy object may cause a compression fracture,” explains Felt.

Cathy Satkus, CPC, COBGC, of Harvard Family Physicians in Tulsa, Oklahoma, recommends that coders look at it this way:

• “Compression fractures occur in the spine and are caused by osteoporosis, weak or brittle bones or an injury.
• “When it is due to injury pain is typically immediate and felt in back, hips, gluteus, arms or legs. In addition to pain there could be numbness or weakness in the arms or legs.
• “When the compression fracture is due to osteoporosis or weak bones the pain might start gradually and get worse over time. Sometimes there is mild, or no pain involved.
• “Compression fractures can also cause loss of height due to the collapse of the vertebrae. There might be impairment of daily living activities, a curved back or kyphosis, digestive problems and trouble breathing.”