Using Dislocation Codes

When it comes to the kind of devastating trauma which whiplash causes to the ligaments of the cervical spine, don’t let the insurance companies off the hook by using the equivalents of diagnoses which they have trained their people to ignore, such as the chiropractic subluxation codes (which the value drivers list ranks between a scrape and a bruise) or the general sprain codes, 847.0, 847.1, and 847.2.  The insurance companies will give their equivalents no more respect than they gave these codes, so why use them?   There are much better codes to use which do a much better job of conveying the severity of the injuries.

Use the M codes for Medicare, as they are intended to be used.  For all other insurance companies, especially including the auto insurance companies, use the S codes whenever possible, as they are intended to convey information concerning trauma.

If you were at my seminar, I presented the ICD-10-CM conversions for the ICD-9-CM codes I have been using up until now.  Here they are again.  First, the old codes:

  • 847.0   Cervical Sprain/Strain
  • 847.2 Lumbar Sprain/Strain
  • 728.4  Laxity of Ligament
  • 738.2 Acquired deformity of the cervical spine
  • 728.5 Hypermobility syndrome of the cervical spine
  • 718.88  Instability of joint, vertebrae
  • 738.4 Acquired spondylolisthesis
  • 723.2  Cervicocranial syndrome

The new codes:

  • 728.4= M24.20 Disorder of ligament, unspecified site
  • 738.2=  M95.3  Acquired deformity of the neck
  • 728.5= M35.7  Hypermobility syndrome
  • 718.88= M24.8  Other specific joint derangements of unspecified joint, not elsewhere classified
  • 738.4= M43.00  Spondylolisthesis, site unspecified, or M43.10  Spondylolisthesis, site unspecified
  • 723.2= M53.0 Cervicocranial syndrome

 The old sprain/strain codes for the cervical spine were always pretty disappointing.  When I heard that there was going to be a new system in place with five times more codes than the original, what I was hoping to see was separate and very specific codes for each of the cervical ligaments, i.e. a code for the left alar ligament, a code for the right alar ligament, a code for the anterior longitudinal ligament specific for the C5-C6 level, and a separate code for the anterior longitudinal ligament for the C3-C4 level, etc.  Well, that didn’t happen.  While there is one code (M48.32) that I found which is specific for the “interspinous ligament, traumatic, cervical region,” the root code “S13.4…” is meant to be “all inclusive for anterior longitudinal ligament, atlas ligaments, atlanto-axial, atlanto-occipital, and whiplash disorder.”  So much for exact specificity, right?  The correct way to use the S13.4 code is as follows:

0 = S13.4XXA Sprain of ligaments of cervical spine, initial encounter
-or-
S13.8XXA  Sprain of joints and ligaments or other parts of neck, initial encounter;
847.1= S23.3XXA  Sprain of ligaments of thoracic spine, initial encounter,
-or-
S23.8XXA  Sprain of other specified parts of thorax, initial encounter;
847.2= S33.5XXA  Sprain of ligaments of lumbar spine, initial encounter.

See what I mean?  You end up using the equivalent of the old sprain/strain codes even though the DMX study you ordered showed you definite, objective proof of demonstrable damage to very specific ligaments in the cervical spine.

Like Captain Binghampton in McHale’s Navy, whenever McHale and the boys of the PT 73 used to out-fox him, used to say, “I could just scream.”

But, I found a solution to this whole mess, so let me explain it to you.

Over a hundred years, the original chiropractors stole the word “subluxation” from the medical dictionary and gave it a new meaning, and used it and used it until they owned it.  They used it to describe a vertebra which had lost its correct anatomical alignment and was pinching on a spinal nerve- the ol’ bone out of place scenario.  What the word means in its medical context is very interesting, especially in relation to our current situation.  Dorland’s Medical Dictionary defines “subluxation” as an “incomplete or partial dislocation.”  A dislocation is a dislocation, whether it is partial, incomplete, or complete, and certain things are implied when the word is used.  It means that two adjacent joint surfaces have lost their anatomical alignment, and this can only occur when the ligaments, which gives the ultimate integrity and stability to the joint, have been disrupted by being stretched beyond their elastic ligaments.  The damage to the ligaments is permanent, and they will never regain their original resting length.  Blood vessels which service the ligament, and the surrounding muscle, are also torn, so there is internal bleeding, or hemorrhage.  The resulting inflammation is painful, and results in myospasm in the short term, and scar tissue invasion in the long term.  The joint is forever changed.  That’s why Krakenes stated, “Lateral shift of the atlas on the axis greater than 1.7 mm. is considered subluxation and associated with poor prognosis for whiplash injury.” (Krakenes J., Kaale, BR, Moen G, Nordli H, Gilhus, NE, Rorvik J.  MRI Assessment of the Alar ligaments in the Late Stage of Whiplash Injury- Structural Abnormalities and Observer Agreement.  Neuroradiology 2002, July:44(7);617-24).  There is no doubt that Dr. Krakenes was using the word “subluxation” in its medical sense, and not in the chiropractic sense.

In the insurance industry’s Colossus system, and other systems, dislocation is given a great deal of weight.  It ranks tenth on the scale of twelve, with twelve being the greatest degree of injury.

INJURY TYPES IN ORDER OF WEIGHTED VALUE (from low to high)

  1. Superficial (Pain)
  2. Abrasion
  3. Chiropractic subluxation
  4. Contusion
  5. Sprain/Strain (Spine)
  6. Ligament/Tendon (Extremities)
  7. Laceration
  8. Crush/Extensive soft tissue/De-Gloving
  9. Bulge/Prolapsed discs/Herniated discs
  10. Dislocation (CCS)
  11. Fracture
  12. Penetrating wound

Notice that #5 and #6 specifically describe ligament injuries, which gives those injuries more weight, but it is still only in the mid-range.  But at #10, there sits dislocation.  And as has already been stated, you cannot have dislocation without ligament injury- in fact, it is the injuries to the ligaments that the term “dislocation” describes.  Note that I placed “CCS” in parentheses next to dislocation, because I want to emphasize that Craniocervical Syndrome (aka cervicocranial syndrome, it really doesn’t matter which part of the word comes first, it’s all the same thing) is probably the most egregious example of the results of ligament subfailure, and the sloppy instability it causes.  One diagnosis you should use whenever it applies is M53.20:  The Cervicocranial Syndrome.  If you didn’t get my write up about Joel Franck, MD, in Newsletter #4, about the incredible transarticular fusion surgery he does to correct C1-C2 lateral instability, please let me know, and I will send it to you.

With that in mind, let’s call these injuries to the cervical spine which are most commonly caused by auto collisions what they are- dislocations!  What’s really cool about this is that the new ICD-10-CM system gives a series of dislocation codes which are specific to each cervical and lumbar level:

  • S13.111A  Dislocation of C0/C1 vertebrae, initial encounter
  • S13.121A  Dislocation of C1/C2 vertebrae, initial encounter
  • S13.131A  Dislocation of C2/C3 vertebrae, initial encounter
  • S13.141A  Dislocation of C3/C4 vertebrae, initial encounter
  • S13.151A  Dislocation of C4/C5 vertebrae, initial encounter
  • S13.161A  Dislocation of C5/C6 vertebrae, initial encounter
  • S13.171A  Dislocation of C6/C7 vertebrae, initial encounter
  • S13.181A  Dislocation of C7/T1 vertebrae, initial encounter
  • S33.101A Dislocation of unspecified lumbar vertebra, initial encounter
  • S33.111A Dislocation of L1/L2 vertebrae, initial encounter
  • S33.121A Dislocation of L2/L3 vertebrae, initial encounter
  • S33.131A Dislocation of L3/L4 vertebrae, initial encounter
  • S33.141A Dislocation of L4/L5 vertebrae, initial encounter

It should go without saying that if you use these codes, you should have a working familiarity with the ligamentous anatomy at the level you use, so that you can defend your choice of coding.

And, remember, you can’t use these codes unless you can provide objective proof of the injury, and the DMX study is the only way you can do it.   I’m sure that there some naysayers out there who would like to argue that the dislocation code for the subaxial joints is only for a situation like perched facets, or the C0-C2 codes are only for injuries like a vertical dislocation of C1 on C2, or a complete failure of the transverse ligament leading to a pathological change in the atlanto-dental interval, but I beg to differ.  The situations I just described are best referred to as “luxations,” which means a complete loss of congruence of adjacent joint surfaces, and are far more serious than subluxations (in the medical sense).  But if you really look at the reality of what happens when there is a laterolisthesis of C1 on C2, or anterolisthesis/retrolisthesis from C2-T1, you will have to come to the conclusion that these injuries fit the definition of medical subluxation.  Yes, I know that there are subluxation codes which are very much like the dislocation codes, and they are meant to describe hypermobility, but when ligaments are subjected to subfailure, let’s call it what is- dislocation. (I don’t think that the writers of the codes had a solid understanding of the nature of the injuries.  I mean, after all, there is a code for “cervical disc displacement, high cervical spine,” an area which does not have discs).  Otherwise, the Colossus system, and other systems like it, will continue to downgrade our diagnoses and give them short shrift.  Let me be clear- our patients who have been injured in motor vehicle collisions have been under-diagnosed for far too long.  A diagnosis code which does not convey the true severity of their injuries is not a diagnosis code you should be using.

If you refer a patient to me for a cervical DMX study, and you use the S13.4 series codes on the medical necessity form, I want you to know that after I read the film and write the report, and document anterolisthesis/retrolisthesis/laterolisthesis in excess of 20%, the insurance claim form I fill out will list these injuries as dislocations.  When you get my report, make sure that you comment on this in your notes, and then adjust your coding accordingly in your billing software.   Remember, if it’s not found in your medical notes, it doesn’t exist.