kristenderosa@gmail.com
Networker
I was wondering if someone could help me out with how to code the scenario below. My question is about using an S code vs an M code since they call the fractures chronic. Any help would be appreciated. Thank you in advance!
Prior compression fractures at T5, T11, L1, L2, and L4, s/p kyphoplasty with IR of L1 several years ago with recent compression fractures of T7 and T1 who presents to ED with a chief complaint pain and failure to thrive. Pt is reported to have fallen 3 weeks ago out of bed, prompting several ED visits, finding an new compression fx.
From Lumbar spine X-RAYS and MR Thoracic spine w/o contrast:
IMPRESSION/FINDINGS:
There are compression fractures with moderate height loss at L1 and L2 and mild height loss at L2, L3, and L5. There are post kyphoplasty changes at L1 and L2.
There is mild apex right curvature of the thoracic spine. There is grade 1 retrolisthesis of L2 on L3, L3 and L4, and L5 on S1. There is grade 1 anterolisthesis of L4 on L5. There is marked disc height loss at L5-S1 and moderate disc height loss at L2-3.
There is moderate multilevel facet hypertrophy of the lower lumbar spine. There is mild to moderate multilevel anterior endplate spurring and endplate sclerosis.
Moderate to severe compression deformity of the T7 vertebra with loss of height by approximately 50%. There is bulging of the posterior cortex into the spinal canal by approximately 4 mm and resultant mild spinal canal narrowing at this level. There is diffuse low signal on T1 weighted images that extends into the pedicles and there is corresponding heterogeneous increased T2 signal on fat saturated images. Findings are nonspecific and likely related to a subacute compression fracture.
Moderate to severe compression fracture of the T11 vertebra with loss of height along the superior plate by approximately 70% similar to the previous study. There is retropulsion of the superior posterior aspect of the vertebra into the spinal canal with resultant mild spinal canal narrowing.
Prior compression fractures at T5, T11, L1, L2, and L4, s/p kyphoplasty with IR of L1 several years ago with recent compression fractures of T7 and T1 who presents to ED with a chief complaint pain and failure to thrive. Pt is reported to have fallen 3 weeks ago out of bed, prompting several ED visits, finding an new compression fx.
From Lumbar spine X-RAYS and MR Thoracic spine w/o contrast:
IMPRESSION/FINDINGS:
There are compression fractures with moderate height loss at L1 and L2 and mild height loss at L2, L3, and L5. There are post kyphoplasty changes at L1 and L2.
There is mild apex right curvature of the thoracic spine. There is grade 1 retrolisthesis of L2 on L3, L3 and L4, and L5 on S1. There is grade 1 anterolisthesis of L4 on L5. There is marked disc height loss at L5-S1 and moderate disc height loss at L2-3.
There is moderate multilevel facet hypertrophy of the lower lumbar spine. There is mild to moderate multilevel anterior endplate spurring and endplate sclerosis.
Moderate to severe compression deformity of the T7 vertebra with loss of height by approximately 50%. There is bulging of the posterior cortex into the spinal canal by approximately 4 mm and resultant mild spinal canal narrowing at this level. There is diffuse low signal on T1 weighted images that extends into the pedicles and there is corresponding heterogeneous increased T2 signal on fat saturated images. Findings are nonspecific and likely related to a subacute compression fracture.
Moderate to severe compression fracture of the T11 vertebra with loss of height along the superior plate by approximately 70% similar to the previous study. There is retropulsion of the superior posterior aspect of the vertebra into the spinal canal with resultant mild spinal canal narrowing.