Spinal level will direct your coding, too.
X-ray, CT, and MRI codes all may come into play in imaging idiopathic scoliosis. And when ICD-10 is implemented in 2014, you’ll have a lot of diagnosis codes to choose from as well. Target the key distinguishing factors with these tips.
ICD-9-CM Code:
ICD-10-CM Codes:
Diagnosis: Scoliosis and kyphoscoliosis are names for abnormal curvature of the spine. The term idiopathic means the disease is of unknown cause.
ICD-9 coding rules: ICD-9 includes 737.30 for idiopathic scoliosis. Take note that there are separate codes for infantile idiopathic scoliosis:
You also should look elsewhere to report congenital scoliosis: 754.2 (Congenital musculoskeletal deformities of spine).
ICD-10 changes: ICD-10’s range M41 (Scoliosis) also includes kyphoscoliosis. ICD-10 divides your idiopathic scoliosis coding options by age range: M41.11- (juvenile), M41.12- (adolescent), and M41.20- (other). For ICD-10, you’ll identify the spinal level by your choice of code, too. For example, the cervical juvenile scoliosis code is M41.112 (Juvenile idiopathic scoliosis, cervical region).
As with ICD-9, ICD-10 has distinct coding options for infantile scoliosis. These are in range M41.0- (Infantile idiopathic scoliosis). Congenital scoliosis also has separate coding options:
Documentation: For you to choose the most specific code, the physician should document the specific spinal area concerned: cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, lumbosacral. You will also need to be able to distinguish between congenital, infantile, juvenile, and adolescent cases.
Coder tips: Don’t confuse kyphosis and kyphoscoliosis. Kyphosis is a front-to-back curvature of the spine. Kyphoscoliosis is when kyphosis and scoliosis (lateral curvature) occur together. Under ICD-10, you’ll use codes from the range M40 (Kyphosis and lordosis) to report kyphosis.
Remember: CMS has finalized the ICD-10 compliance date of Oct. 1, 2014. When ICD-10 goes into effect, you should apply the code set and official guidelines in effect for the date of service reported. Learn more at www.cms.gov/ICD10/ and www.cdc.gov/nchs/icd/icd10cm.htm#10update.