Reporting Scoliosis – An Overview of the Condition and Medical Codes

Regarded as a common spine condition that affects people of all age groups, (including children, teenagers and adults), scoliosis causes the spine or backbone to curve sideways. This condition can affect any part of the spine, but the most common regions are the chest area in the thoracic and thoracic-lumbar regions mainly due to congenital or degenerative problems. The exact cause of scoliosis is unknown as several hereditary factors, birth defects, medical conditions (like cerebral palsy and muscular dystrophy) and injuries and infections of the spine tend to play a prominent role. However, early diagnosis and correct treatment is essential to get better outcomes. Proper documentation is important to ensure appropriate care and for accurate clinical documentation of this spinal disorder, physicians rely on the services of reliable medical billing and coding outsourcing companies.

According to the National Scoliosis Foundation (NSF), scoliosis affects about 7 million people in the United States each year. People of all ages can develop scoliosis. The condition is typically seen among children aged between 10-12 years and is more common in girls than in boys. Children often develop spine deformities that continue to get more severe as they grow. Severe scoliosis can reduce the amount of space within the chest, making it difficult for the lungs to function properly. If left untreated, this condition can significantly impact the quality of life with limited activity, pain and reduced respiratory function.

Types of Scoliosis

Scoliosis is generally categorized into five types-

• Congenital scoliosis – when the spine does not form correctly before birth.
• Adolescent idiopathic scoliosis – causes curving and twisting of the spine.
• Degenerative scoliosis – occurs due to wear and tear of the skeletal system (most common among adults)
• Neuromuscular scoliosis – occurs when nerve abnormalities affect muscles in the spine.
• Syndromic scoliosis – linked to one of a range of syndromes, including Marfons syndrome and trisomy 21

Early Diagnosis and Treatment

Generally, scoliosis symptoms become apparent from infancy or adolescence. Common signs and symptoms associated with the spinal condition include –

• Uneven shoulders
• One shoulder blade that appears more prominent than the other
• One hip higher than the other
• Leg and hip pain
• Knee pain
• Headache
• Difficulty in breathing
• Chronic fatigue and future spinal kyphosis (widow’s hump)
• Back pain
• A tendency to lean to one side

The potential risk factors associated with this condition include – age, family history and sex. Most people with scoliosis (even a mild form) may sometimes cause several complications like – lung and heart damage, back problems and shoulder appearance.

Diagnosis of this spinal condition will begin with a detailed physical and neurological examination to check for muscle weakness, numbness and abnormal reflexes. A complete analysis of past medical history will be done and physicians will ask questions about the recent growth. Orthopedists or other specialists may recommend several diagnostic imaging tests like X-ray or MRI scan of the lumbar spine as these will help analyze the range and severity of spinal curvature.

Treatment modalities for this condition may depend on several factors such as patient age, type, severity of curves, intensity of symptoms and growth, and location of symptoms. For those who suffer from mild or moderate cases of scoliosis, physicians may advise wearing a brace – which helps to prevent further progression of the curve. Other common treatment modalities include – physical therapy exercises, Transcutaneous Electrical Nerve Stimulation (TENS) and chiropractic therapy. In case of severe scoliosis, spinal fusion surgery may be considered as a last resort to reduce the severity of the spinal curve and to prevent it from getting worse.

Orthopedics medical billing and coding is challenging as it involves several rules related to reporting the condition correctly. Orthopedists or other spinal specialists who treat scoliosis must use the relevant ICD-10 and CPT codes to bill for the procedure. The medical codes used to report scoliosis include –

ICD -10 Codes

M41 – Scoliosis

M41.0 – Infantile idiopathic scoliosis

• M41.00 – Infantile idiopathic scoliosis, site unspecified
• M41.02 – Infantile idiopathic scoliosis, cervical region
• M41.03 – Infantile idiopathic scoliosis, cervicothoracic region
• M41.04 – Infantile idiopathic scoliosis, thoracic region
• M41.05- Infantile idiopathic scoliosis, thoracolumbar region
• M41.06 – Infantile idiopathic scoliosis, lumbar region
• M41.07 – Infantile idiopathic scoliosis, lumbosacral region
• M41.08 – Infantile idiopathic scoliosis, sacral and sacrococcygeal region

M41.1 – Juvenile and adolescent idiopathic scoliosis

• M41.11 – Juvenile idiopathic scoliosis
• M41.112 – Juvenile idiopathic scoliosis, cervical region
• M41.113 – Juvenile idiopathic scoliosis, cervicothoracic region
• M41.114 – Juvenile idiopathic scoliosis, thoracic region
• M41.115 – Juvenile idiopathic scoliosis, thoracolumbar region
• M41.116 – Juvenile idiopathic scoliosis, lumbar region
• M41.117 – Juvenile idiopathic scoliosis, lumbosacral region
• M41.119 – Juvenile idiopathic scoliosis, site unspecified

M41.12 – Adolescent scoliosis

• M41.122 – Adolescent idiopathic scoliosis, cervical region
• M41.123 – Adolescent idiopathic scoliosis, cervicothoracic region
• M41.124 – Adolescent idiopathic scoliosis, thoracic region
• M41.125 – Adolescent idiopathic scoliosis, thoracolumbar region
• M41.126 – Adolescent idiopathic scoliosis, lumbar region
• M41.127 – Adolescent idiopathic scoliosis, lumbosacral region
• M41.129 – Adolescent idiopathic scoliosis, site unspecified

M41.2 – Other idiopathic scoliosis

• M41.20 – Other idiopathic scoliosis, site unspecified
• M41.22 – Other idiopathic scoliosis, cervical region
• M41.23 – Other idiopathic scoliosis, cervicothoracic region
• M41.24 – Other idiopathic scoliosis, thoracic region
• M41.25 – Other idiopathic scoliosis, thoracolumbar region
• M41.26 – Other idiopathic scoliosis, lumbar region
• M41.27 – Other idiopathic scoliosis, lumbosacral region

M41.3 – Thoracogenic scoliosis

• M41.30 – Thoracogenic scoliosis, site unspecified
• M41.34 – Thoracogenic scoliosis, thoracic region
• M41.35 – Thoracogenic scoliosis, thoracolumbar region

M41.4 – Neuromuscular scoliosis

• M41.40 – Neuromuscular scoliosis, site unspecified
• M41.41 – Neuromuscular scoliosis, occipito-atlanto-axial region
• M41.42 – Neuromuscular scoliosis, cervical region
• M41.43 – Neuromuscular scoliosis, cervicothoracic region
• M41.44 – Neuromuscular scoliosis, thoracic region
• M41.45 – Neuromuscular scoliosis, thoracolumbar region
• M41.46 – Neuromuscular scoliosis, lumbar region
• M41.47 – Neuromuscular scoliosis, lumbosacral region

M41.5 – Other secondary scoliosis

• M41.50 – Other secondary scoliosis, site unspecified
• M41.52 – Other secondary scoliosis, cervical region
• M41.53 – Other secondary scoliosis, cervicothoracic region
• M41.54 – Other secondary scoliosis, thoracic region
• M41.55 – Other secondary scoliosis, thoracolumbar region
• M41.56 – Other secondary scoliosis, lumbar region
• M41.57 – Other secondary scoliosis, lumbosacral region

M41.8 – Other forms of scoliosis

• M41.80 – Other forms of scoliosis, site unspecified
• M41.82 – Other forms of scoliosis, cervical region
• M41.83 – Other forms of scoliosis, cervicothoracic region
• M41.84 – Other forms of scoliosis, thoracic region
• M41.85 – Other forms of scoliosis, thoracolumbar region
• M41.86 – Other forms of scoliosis, lumbar region
• M41.87 – Other forms of scoliosis, lumbosacral region

M41.9 – Scoliosis, unspecified

CPT Codes

• 22800 – Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments
• 22802 – Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments
• 22804 – Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments
• 22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments
• 22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments
• 22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments
• 22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments
• 22819 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments

HCPCS Codes

• L1290 – Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), lateral trochanteric pad
• L1300 – Other scoliosis procedure, body jacket molded to patient model
• L1310 – Other scoliosis procedure, postoperative body jacket
• L1499 – Spinal orthotic, not otherwise specified

Knowing the highly specific ICD-10 codes related to documenting injuries is critical for providers. Partnering with a reliable and experienced medical billing and coding company is important for physicians to ensure accurate and timely claim submissions.