ICD Coding for Acute Cervical Spinal Cord Injuries

Introduction: Guidelines for management of acute spinal cord injury (SCI) are based on young age group with high-impact trauma suffering spinal fracture dislocations. Our objective is to characterize recent cervical SCI experience and evaluate ICD coding for acute cervical spinal cord injuries.

Methods: Cross-Sectional Cohort Study. A detailed review was performed of cSCI patients admitted to our Level 1 trauma institution over a 12-month period identifying injury types and coded diagnoses. In tandem, the NIS database was queried over a three-year period to identify coded diagnoses for acute cervical spinal cord injuries.

Results: 82% of acute cervical SCI at our level 1 trauma center did not have spinal fracture or dislocation compared to 15% in the NIS database (p < 0.01). patients without fracture dislocations were assigned ICD-10 codes at our institution of M54.2 for cervicalgia (33%); M48.02 for spinal stenosis, cervical region (21%); G95.9 for disease of spinal cord, unspecified (10%); G95.2 for other and unspecified cord compression (7%); and S12 for cervical spine fracture (7%) (even though there was no fracture); M47.12 for other spondylosis with myelopathy, cervical region (5%); M54.12 for radiculopathy, cervical region (2%); S14.12 for central cord syndrome of cervical spinal cord (2%); S14.109 for unspecified injury at unspecified level of cervical spinal cord (2%); and M50.90 for cervical disc disorder, unspecified, unspecified cervical region (2%).

Conclusion : While the most common type of cSCI has shifted to an older demographic with preexisting cervical spondylosis subjected to low level trauma without fracture/dislocation, the NIS database does not reliably detect these patients. Large sample studies are currently not feasible because of coding ambiguities at both local and national levels.