Wiki 7th character question....

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tmarugg

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Our patient had a previous lumbar fusion in 2012 by another physician. He came to our doctor because of low back pain. After ordering a CT of the lumbar spine, it showed pseudoarthrosis of the lumbar area. The diagnosis code we have been given by the physician is pseudoarthrosis. When we look in the ICD 10 code book, it asks for a 7th character. This is where things get to be uncertain for us. On one hand, pseudoarthrosis would indicate there is a non-union of a previous fracture, but nowhere in the patients chart is a previous fracture mentioned. So should we ask for another diagnosis code?

On the other hand, since the patient is not seeing us for treatment of a fracture, should we select the 7th character A or K.

Thanks in advance!
 
So you will need to know if the pseudoarthrosis is due to a fracture nonunion and then you will code the fracture code and a nonunion subsequent. Or is it due to a failed fusion in which case you go to the M96.0 code which needs no 7th character. But your provider must be the one that drives which choice this is.
 
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