Orthopedic Coding Alert

Question: Notes indicate that the orthopedist saw an established patient recovering from a traumatic rupture of the intervertebral disc. Notes indicate a level-three evaluation and management (E/M) service. How should I code this encounter?

Wyoming Subscriber

Answer: You’ll need more information on the exact location and nature of the rupture before adding an ICD-10 code to your 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity … ) claim.

If the patient’s injury is to the cervical intervertebral disc, report S13.0XX_ (Traumatic rupture of cervical intervertebral disc).

If the patient’s injury is to the thoracic intervertebral disc, report S23.0XX_ (Traumatic rupture of thoracic intervertebral disc).

If the patient’s injury is to the lumbar intervertebral disc, report S33.0XX_ (Traumatic rupture of lumbar intervertebral disc).

Remember your place … holders: Regardless of the ICD-10 code you choose from those above, you’ll need to include a seventh character to represent whether the encounter for this particular injury is initial (A), subsequent (D), or sequela (S). In order for the code to reach the seven-digit mark, you’ll need to use placeholder ‘X’ for digits five and six.