Radiology Coding Alert

Question: Our physician documented a diagnosis of subluxation of the lumbar and sacral spine. The documentation also described degeneration of discs in the lumbar region? How can we report these diagnoses?

Mississippi Subscriber

Answer: For lumbar and sacral subluxation, you look for codes in the category of ‘other dorsopathies.’ You can report M99.03 (Segmental and somatic dysfunction of lumbar region) as the primary diagnosis, followed by a secondary diagnosis of M51.36 (Other intervertebral disc degeneration, lumbar region) and M51.37 (Other intervertebral disc degeneration, lumbosacral region).

Check if your physician has also documented a neuromuscular complaint in this patient. If yes, you can also submit code M99.84 (Other biomechanical lesions of sacral region).

Note: For congenital lumbosacral subluxation, you submit code include Q76.2 (Congenital spondylolisthesis).