ICD-10 Coding for Spinal Injury(S14.109A)
Complete ICD-10-CM coding and documentation guide for Spinal Injury. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Spinal Injury
S14-S34Primary Range
Injuries to the spinal cord and vertebrae
This range covers all types of spinal injuries, including those affecting the cervical, thoracic, and lumbar regions.
Key Information: ICD-10 code for cervical spinal cord injury
Essential facts and insights about Spinal Injury
Primary ICD-10-CM Code for spinal injury
Decision Criteria
clinical Criteria
- Presence of neurological deficits without vertebral fracture
documentation Criteria
- Detailed ASIA scale and MRI findings
Applicable To
- Cervical spinal cord injury without fracture
Excludes
- Cervical vertebral fracture (S12.-)
Clinical Validation Requirements
- MRI showing cord edema
- ASIA Impairment Scale assessment
- Absence of vertebral fracture
Code-Specific Risks
- Misclassification if vertebral injury is present
- Inaccurate ASIA scale documentation
Coding Notes
- Ensure detailed documentation of neurological deficits and imaging results.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Chronic pain due to trauma
G89.21Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Fracture of cervical vertebra
S12.300ADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Spinal Injury to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S14.109A.
Impact
Clinical: Inaccurate assessment of injury severity., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to incomplete documentation.
Mitigation Strategy
Use standardized templates for spinal injury documentation, Regular training on ASIA scale usage
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Poor data quality affecting clinical outcomes.
Mitigation Strategy
Always document and code the specific level of spinal injury (e.g., C5-C6).
Impact
Failure to document the ASIA scale can lead to audit issues.
Mitigation Strategy
Implement mandatory ASIA scale documentation for all spinal injuries.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Spinal Injury, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Spinal Injury
Use these documentation templates to ensure complete and accurate documentation for Spinal Injury. These templates include all required elements for proper coding and billing.
Cervical spinal cord injury without fracture
Specialty: NeurologyRequired Elements
- ASIA Impairment Scale
- MRI findings
- Neurological examination
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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