Eli's Rehab Report

Question: Our physiatrist just started seeing a new patient who didnt respond to back surgery by an orthopedic surgeon and is now trying alternative treatment methods. The physiatrist recorded her diagnosis in the chart as failed back syndrome. Is there an ICD-9 code for this?

Texas Subscriber

Answer: Its always a challenge when physicians use their own terms rather than more established jargon to describe a condition or procedure. In this situation, 996.4 (mechanical complication of internal orthopedic device, implant, and graft) may be appropriate. But 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, reporting 722.83 (postlaminectomy syndrome; lumbar region) as the primary code is appropriate. Of course, the coder should go back to the physiatrist and ask for a more detailed explanation of the patients condition. He or she may advise the coder to use the codes for the patients presurgical diagnosis, such as a herniated lumbar disk (722.10).