Orthopedic Coding Alert

Question: How should I code failed back syndrome?

Texas Subscriber

Answer: Its always a challenge when physicians use their own terms, rather than more established jargon to describe a condition or procedure. The term failed back syndrome implies that the patient has had prior back surgery with poor results. For example, the patient returns with the same complaint he or she had prior to surgery, and/or has severe pain.

In this situation, 996.4 (mechanical complication of internal orthopedic device, implant, and graft) may be appropriate. However, 996.4 is applicable only if an internal fixation device or spine fusion has failed. In the case of failed fusion, use 996.4 as the primary diagnosis and V45.4 (arthrodesis status) as the secondary code.

If the patient has continued symptoms after a lumbar laminectomy, it is appropriate to report 722.83 (postlaminectomy syndrome; lumbar region) as the primary code.