February 1, 2010

Coding for Spinal Cord Injuries
For The Record
Vol. 22 No. 2 P. 29

Spinal cord injuries cause loss of movement and sensation and may damage all or part of the corresponding muscles and nerves below the injury site. Two factors are considered to determine the amount of control available in the limbs:

• the neurological level, or the lowest normally functioning segment of the spinal cord; and

• the completeness of the spinal cord injury, which may be described as either complete or incomplete. Complete means that all the sensory and motor function is lost below the neurological level. Incomplete means the patient may maintain some motor or sensory function below the affected area.

Loss of movement due to spinal cord injuries may be described as quadriplegia (or tetraplegia), which affects the arms, trunk, legs, and pelvic organs, or paraplegia, which affects all or part of the trunk, legs, and pelvic organs.

A spinal cord injury may result from a sudden forceful blow to the spine that fractures, dislocates, crushes, or compresses one or more of the vertebrae or a wound that cuts the spinal cord. Nontraumatic spinal cord injuries may be caused by arthritis, cancer, inflammation, infections, or disk degeneration of the spine.

Traumatic spinal cord injury is classified to ICD-9-CM category 952. The fourth-digit subcategory identifies the location of the spinal cord affected, such as cervical, thoracic, and lumbar. There are also codes available for spinal cord injury of the sacrum (952.3) and cauda equina (952.4). A fifth digit is required if the injury affected the cervical or thoracic area. The fifth-digit subclassification provides greater specificity as to the injury location on the cervical or thoracic cord. It also identifies whether the injury was described as a complete lesion of the spinal cord, anterior cord syndrome, central cord syndrome, posterior cord syndrome, or an incomplete spinal cord lesion.

If the spinal cord injury occurs with a fracture of the vertebral column, then a code from category 806 will be assigned instead of from category 952. The fourth-digit subcategory identifies the fracture location and whether the fracture was open or closed. If a fifth-digit subclassification is required under category 806, it follows the same logic as category 952.

A fracture of the vertebral column without spinal cord injury is classified to category 805.

Symptoms
Spinal cord injuries of any kind may include the following signs and symptoms:
• loss of movement;

• extreme pain or pressure in head, neck, or back;

• loss of sensation (inability to feel heat, cold, and touch);

• numbness or tingling in hands, fingers, feet, or toes;

• difficulty with balance;

• loss of bowel or bladder control;

• exaggerated reflex activities or spasms;

• changes in sexual function;

• an intense stinging sensation;

• difficulty breathing after injury; or

• an oddly positioned or twisted neck or back.

The spinal cord injury may not be apparent at first. However, it may become more noticeable when bleeding and/or swelling occur around the spinal cord.

Diagnosis
The physician may check for spinal cord injury by testing the sensory function and movement using x-rays, CT scans, MRI, or myelography. He or she may order some of the same tests or diagnostic studies after the swelling has gone down to reevaluate the condition of the spinal cord.

Treatment
There is no way to reverse the damage of a spinal cord injury. Treatment focuses on preventing further injury and working with patients to return to an active and productive life. Immediate treatment involves immobilizing the spine at the accident site to prevent further spinal cord damage, maintaining breathing, and preventing shock. At the hospital, the physician may order methylprednisolone to reduce inflammation and damage to nerve cells. Traction, such as a halo device, may be used to stabilize or align the spine. Surgery may be needed to remove bone fragments, foreign bodies, and herniated disks.

Coding and sequencing for spinal cord injuries are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.