Neurosurgery Coding Alert

Question: How should I apply late effects codes? For instance, what primary diagnosis should I report if the surgeon is treating a patient for late effects of spinal fracture from an auto accident?


Montana Subscriber

Answer: When you report late effects of an acute injury, your primary diagnosis should be the residual problem or condition that brought the patient to your office. You should list the appropriate late effects code as a secondary diagnosis, according to section 1.7 of the Official ICD-9-CM Guidelines for Coding and Reporting.

In your case, the patient injures his spinal cord in an auto accident. Some time later, the patient has problems related to the previous injury and consults with the surgeon for treatment.

You should first report the spinal cord injury (for example, 952.x, Spinal cord injury without evidence of spinal bone injury)--even though the acute phase of the injury has passed--and the late effects (907.2, Late effect of spinal cord injury) as a secondary diagnosis.

Reporting only the spinal cord injury would make it appear as if it were a new, acute injury. By appending the late effects code, however, you indicate the presence of problems resulting from the previous injury.

Caution: Don't confuse late effects with complications: The two are not the same. A complication describes a problem arising from a condition that still exits. A late effect, on the other hand, is caused by a condition no longer in its acute phase.