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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 1
Presented by:
Teri Romano, RN, MBA, CPC, CMDP
Source: http://journal.ahima.org/2015/02/04/us‐house‐committee‐to‐hold‐hearing‐on‐icd‐10‐implementation/
ICD‐10‐CM IMPLEMENTATION DATE
OCT 1, 2015
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 2
ICD‐9‐CM
vs.
ICD‐10‐CM
• 3‐5 characters in length • 3‐7 characters in length
• 1st character may be alpha, but is usually numeric; 2nd‐5th characters are numeric
• Character 1 is alpha, character 2 is always numeric, characters 3‐7 can be either alpha or numeric
• Approximately 14,000 codes • Approximately 69,000 codes
• Limited space for adding new codes • Flexibility for adding new codes
• Lacks detail • Very specific
3
Example: S12
Fracture of cervical vertebra and other parts of neck
Note: A fracture not indicated as displaced or nondisplaced should be coded to displaced
A fracture not indicated as open or closed should be coded to closed
Includes: Fracture of cervical neural arch
Fracture of cervical spine
Fracture of cervical spinous process
Fracture of cervical transverse process
Fracture of cervical vertebral arch
Fracture of neck4
2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 3
Excludes Notes
The ICD‐10‐CM has two types of excludes notes (recall that ICD‐9‐CM had only one type of excludes notes).
Excludes1
Excludes2
5
Excludes1 This is a “pure” excludes. It means 'NOT CODED HERE!' and the code excluded should never be used at the same time as the code above the Excludes1 note.
M48.5‐ Collapsed vertebra, not elsewhere classified
Excludes 1 Current injury‐see injury of spinepathological fracture of vertebra due to neoplasm (M84.58)
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 4
Excludes2Means NOT INCLUDED HERE. An Excludes2 note indicates that the condition is not part of the condition represented by the code, but a patient could possibly have both conditions at the same time. In this case, it could be acceptable to use both the code and the excluded code together; such as:
M51‐ Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders
Excludes2 Cervical and cervicothoracic disc disorder (M50.‐)
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“Other” or “Other Specified” ( Not Elsewhere Classified—NEC)
Use when information in the medical record provide detail for which a specific code does not exist.
Specific disease is documented but there is no diagnosis code.
“Unspecified” ( Not Otherwise Specified‐ NOS)
Use when the information in the medical record is insufficientto assign a more specific code.
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 5
CHAPTER 13 : DISEASES OF THE MUSCULOSKELETAL SYSTEM
AND CONNECT IVE T ISSUE(M00 ‐M99)
M00‐M99
M
Chapter Organization
Image sources: http://en.wikipedia.org/wiki/File:Captainmarvel.JPG 10
2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 6
This chapter BLOCK is broken down into the following categories:M00‐M02 Infectious arthropathies
M05‐M14 Inflammatory polyarthropathies
M15‐M19 Osteoarthritis
M20‐M25 Other joint disorders
M26‐M27 Dentofacial anomalies and other jaw disorders
M30‐M36 Systemic connective tissue disorders
M40‐M43 Deforming dorsopathies (e.g., kyphosis, scoliosis, spondylolysis, spondylolisthesis)
M45‐M49 Spondylopathies (e.g., osteomyelitis of vertebra, infection of intervertebral disc, discitis, spondylosis, spinal stenosis)
M50‐M54 Other dorsopathies (e.g., disc disorders, spinal instabilities, radiculopathy, sciatica, lumbago, low back pain)
M60‐M63 Disorders of muscles (e.g., myositis)
M65‐M67 Disorders of synovium and tendon (e.g., trigger finger)
M70‐M79 Other soft tissue disorders (e.g., spinal synovial cyst)
M80‐M85 Disorders of bone density and structure (e.g., osteoporosis with current pathological fracture, pathological fracture in neoplastic disease)
M86‐M90 Other osteopathies (e.g., osteomyelitis, osteonecrosis)
M91‐M94 Chondropathies
M95 Other disorders of the musculoskeletal system and connective tissue
M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified (e.g., fracture following insertion of implant, puncture, laceration, hemorrhage)
M99 Biomechanical lesions, not elsewhere classified
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SPINE DISORDER WHERE YOU’LL FIND IT
Stenosis, disc, spondylolisthesis, spondylosis, degenerative scoliosis/kyphosis
M40‐M99.9 Musculoskeletal ChapterChapter 13
Spine fractures, spinal cord injury, traumatic disc, subluxation, etc
S12‐ S34.9‐ Injuries, Poisonings and Other Consequences of External Causes Chapter 19
Spinal and vertebral tumors C and D Neoplasms Chapter 2
Spinal abscesses, cysts, chronic pain, dural tear
G00‐G99.8 Nervous System Chapter 6
Complications of devices ( spine hardware, neurostimulator, etc)Post‐op wound infection, spine
T81‐T88.9 Injuries, Poisonings and Other Consequences of External Causes Chapter 19
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 7
SPINE DISORDER WHERE YOU’LL FIND IT
Stenosis, disc, spondylolisthesis, spondylosis, degenerative scoliosis/kyphoses
M40‐M99.9 Musculoskeletal ChapterChapter 13
Spine fractures, spinal cord injury, traumatic disc, subluxation, etc
S12‐ S34.9‐ Injuries, Poisonings and Other Consequences of External Causes Chapter 19
Spinal and vertebral tumors C and D Neoplasms Chapter 2
Spinal abscesses, cysts, chronic pain, dural tear G00‐G99.8 Nervous System Chapter 6
Complications of devices ( spine hardware, neurostimulator, etc)Post‐op wound infection, spine
T81‐T88.9 Injuries, Poisonings and Other Consequences of External Causes Chapter 19
13
Major Differences for Non‐Traumatic Spine?
Site specific, (occipito‐atlanto‐axial, high cervical)
Combination codes (with myelopathy and radiculopathy)
Character X and the 7Th character for healing status
Clinical concepts added (radiculopathy)
Codes expanded (increased sites and increased categories of codes)
Complications expanded
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 8
M40: Kyphosis and lordosis
M40.‐ Postural
M40.1‐ Other secondary kyphosis
M40.2‐ Other and unspecified kyphosis
M40.3‐ Flatback syndrome
M40.4‐ Postural lordosis, acquired lordosis
M40.5‐ Lordosis, unspecified
Tip: Use M96.‐ for post‐procedural kyphosis, scoliosis, etc.
Additional character(s) required for specific spinal region for the M40‐M43 code block.
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M41: Scoliosis M41.0‐ Infantile idiopathic scoliosis
M41.1‐ Juvenile and adolescent idiopathic scoliosis
M41.2‐ Other idiopathic scoliosis
M41.3‐ Thoracogenic scoliosis
M41.4‐ Neuromuscular scoliosis (e.g., scoliosis secondary to cerebral palsy)
M41.5‐ Other secondary scoliosis
M41.8‐ Other forms of scoliosis
M41.9 Scoliosis, unspecified
Additional character(s) required for specific spinal region for the M40‐M43 code block.
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 9
M43.0‐ Spondylolysis
M43.1‐ Spondylolisthesis (excludes traumatic and congenital)
0 site unspecified
1 occipito‐atlanto‐axial (C1‐C2)
2 cervical
3 Cervicothoracic
4 thoracic
5 thoracolumbar
6 Lumbar
7 lumbosacral
8 sacral and sacrococcygeal
9 multiple sites
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M47.82‐Other Spondylosis with
Radiculopathy
M47.1‐ Spondylosis
5th Character
0 Site unspecified
1 Occipito‐atlanto‐axial (Occiput – C2)
2 Cervical (C1 – C7)
3 Cervicothoracic (C7 – T1)
4 Thoracic (T1 – T12)
5 Thoracolumbar (T12 – L1)
6 Lumbar (L1 – L5)
7 Lumbosacral (L5 – S1)
8 Sacral and sacrococcygeal
6th Character
1 Occipito‐atlanto‐axial (Occiput – C2)
2 Cervical (C1 – C7)
3 Cervicothoracic (C7 – T1)
4 Thoracic (T1 – T12)
5 Thoracolumbar (T12 – L1)
6 Lumbar (L1 – L5)
7 Lumbosacral (L5 – S1)
8 Sacral and sacrococcygeal
9 Site unspecified
M47.1‐Other spondylosis with Myelopathy
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 10
M47.81‐Spondylosis without myelopathy or
radiculopathy
M47.‐ Spondylosis
6th Character
1 Occipito‐atlanto‐axial (Occiput – C2)
2 Cervical (C1 – C7)
3 Cervicothoracic (C7 – T1)
4 Thoracic (T1 – T12)
5 Thoracolumbar (T12 – L1)
6 Lumbar (L1 – L5)
7 Lumbosacral (L5 – S1)
8 Sacral and sacrococcygeal
9 Site unspecified
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M47.89‐ Other spondylosis, by site
M47.9 Spondylosis, unspecified
M48.0‐ Spinal stenosis
5th Character
0 Site unspecified
1 Occipito‐atlanto‐axial (Occiput – C2)
2 Cervical (C1 – C7)
3 Cervicothoracic (C7 – T1)
4 Thoracic (T1 – T12)
5 Thoracolumbar (T12 – L1)
6 Lumbar (L1 – L5)
7 Lumbosacral (L5 – S1)
8 Sacral and sacrococcygeal
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 11
M54.01‐ Radiculopathy
5th Character
0 Site unspecified
1 Occipito‐atlanto‐axial (Occiput – C2)
2 Cervical (C1 – C7)
3 Cervicothoracic (C7 – T1)
4 Thoracic (T1 – T12)
5 Thoracolumbar (T12 – L1)
6 Lumbar (L1 – L5)
7 Lumbosacral (L5 – S1)
8 Sacral and sacrococcygeal
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New in ICD‐10
M46.2‐ Osteomyelitis of vertebra M46.4‐ Discitis
5th Character
0 Site unspecified
1 Occipito‐atlanto‐axial (Occiput – C2)
2 Cervical (C1 – C7)
3 Cervicothoracic (C7 – T1)
4 Thoracic (T1 – T12)
5 Thoracolumbar (T12 – L1)
6 Lumbar (L1 – L5)
7 Lumbosacral (L5 – S1)
8 Sacral and sacrococcygeal
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 12
M50.‐ Cervical: requires 5th character for all subcategories listed below
5th Character
0 Unspecified region
1 High cervical region (C2‐C3, C3‐C4)
2 Mid‐cervical region (C4‐C5, C5‐C6, C6‐C7)
3 Cervicothoracic region (C7‐T1)
M50.0‐ With myelopathy
M50.1‐ With radiculopathy
M50.2‐ Other disc displacement
M50.3‐ Other disc degeneration
M50.8‐ Other disc disorders
M50.9 Unspecified
Code to the most superior level!
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M51.‐ Thoracic, thoracolumbar and lumbosacral: requires 5th character for all subcategories listed below
5th Character
4 Thoracic (T1‐T12)
5 Thoracolumbar (T12‐L1)
6 Lumbar (L1‐L5)
7 Lumbosacral (L5‐S1)
M51.0‐ With myelopathy M51.1‐ With radiculopathy M51.2‐ Other disc displacement M51.3‐ Other disc degeneration
M51.4‐ Schmorl’s nodes M51.8‐ Other disc disorders M51.9 Unspecified
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 13
M54.2 Cervicalgia
M54.3‐ Sciatica
New!! Unspecified side, right, left
M54.4‐ Lumbago with sciatica
New!! Unspecified side, right, left
M54.5 Low back pain
M54.6 Pain in thoracic spine
M54.9 Dorsalgia, unspecified.
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Code symptoms only when a more definite diagnosis is not known.
M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified.
Examples:
M96.0 Pseudarthrosis after fusion or arthrodesis
M96.1 Postlaminectomy syndrome, not elsewhere classified
M96.81‐ Intraoperative hemorrhage and hematoma
M96.83‐ Postprocedural hemorrhage and hematoma
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 14
“Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.”
For example: Code the primary reason for the visit (lumbar stenosis) but code underlying conditions if they affect your treatment/surgical plan. For example, are you sending the patient to their cardiologist for a pre‐op evaluation for co‐existing cardiac conditions? Code those conditions. Important for risk based contracting and potential future payment models such as bundled payments and ACOs.
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“X” placeholder is used to provide room for future expansion
“X” placeholder is used to keep applicable 7th character in the 7th position when the code is less than 6 characters long.
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 15
M53.2 Spinal instabilities
M53.2X1 Spinal instabilities, occipito‐atlanto‐axial region
M53.2X2 Spinal instabilities, cervical region
M53.2X3 Spinal instabilities, cervicothoracic region
M53.2X4 Spinal instabilities, thoracic region
Etc.
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“X” placeholder is used to provide room for future expansion.
“X” placeholder is used to keep the 7th character in the 7th
position when a code is less than 6 characters long.
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 16
For Fractures 6 optionsThe appropriate 7th character is to be added to each code from category S02
A ‐ initial encounter for closed fracture
B ‐ initial encounter for open fracture
D ‐ subsequent encounter for fracture with routine healing
G ‐ subsequent encounter for fracture with delayed healing
K ‐ subsequent encounter for fracture with nonunion
S ‐ sequela
For Non‐Fractures 3 optionsThe appropriate 7th character is to be added to each code from category S14
A ‐ initial encounter
D ‐ subsequent encounter
S ‐ sequela
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Initial Encounter (A, B) = In Active Treatment
Examples include: surgical treatment, emergency department encounter and evaluation and continuing treatment by a new or the same
physician. (2015 Guideline update!)
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 17
Subsequent Encounter (D, G, K, P) = In Healing or Recovery Phase
Examples include: cast change or removal, an x‐ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition
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Sequela (S) = Late effect, residual effect of a prior condition‐ not a complication
Examples include: scar formation resulting from a burn, deviated septum due to nasal fracture, infertility due to tubal occlusion from prior disease
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Diagnosis
(ICD‐10‐CM) Coding
Procedure
(CPT) CodingTerm Encounter VisitType Initial: the patient is in the
active phase or treatment for an injury or fracture
New patient: the patient has not been seen by the physician or other qualified health care provider in the same specialty, same group in the past 3 years
Subsequent: after the active treatment phase is over
Established patient: the patient has been seen by a physician or other qualified health care provider in the same specialty, same group practice within the past 3 years
7th Character
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 19
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Chapter Highlights – Pathologic Fracture/ Osteoporosis Related
M80
M80.08‐ √ x 7th
Osteoporosis with current pathological fracture, vertebra(e)
M80.88‐ √ x 7th
Other osteoporosis with current pathological fracture, vertebra(e)
39Image source: http://upload.wikimedia.org/wikipedia/commons/1/17/Blausen_0250_CompressionFracture_Vertebrae.png
Chapter Highlights –Pathologic Fracture in Neoplastic Disease
M84
M84.58‐ √ x 7th
Pathological fracture in neoplastic disease, other specified site (vertebrae)
Code also underlying neoplasm
Image source: http://upload.wikimedia.org/wikipedia/commons/1/17/Blausen_0250_CompressionFracture_Vertebrae.png 40
2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 21
Coding of Pathologic Fractures
For pathological fractures
The appropriate 7th character
A initial encounter for fracture
D subsequent encounter for fracture w/ routine healing
G subsequent encounter for fracture w/ delayed healing
K subsequent encounter for fracture w/ nonunion
P subsequent encounter for fracture w/ malunion
S sequela
41Image source: http://upload.wikimedia.org/wikipedia/commons/1/17/Blausen_0250_CompressionFracture_Vertebrae.png
Fatigue fractures (M48.40‐M48.48) (A type of stress fracture due to abnormal stress on normal bone)
Collapsed vertebra (M48.50‐M48.58 Codes)
Each of these categories of codes will need an X placeholder for a valid code.
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 22
For fatigue fractures and collapsed vertebra 4 options
The appropriate 7th character is to be added to each code
A ‐ initial encounter for closed fracture
D ‐ subsequent encounter for fracture with routine healing
G ‐ subsequent encounter for fracture with delayed healing
S ‐ sequela
43
All will require a 7th character:
T81.4 Infection following a procedure
T84.84 Pain due to orthopedic internal prosthetic device, implants and grafts. (painful hardware)
T85.1‐Mechanical complication of implanted electronic stimulator of nervous system ( codes for breakdown, displacement, other)
T84.2‐ Breakdown, displacement, other of internal fixation device of vertebrae
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 23
3 options
The appropriate 7th character is to be added to each code
A ‐ initial encounter
D ‐ subsequent encounter
S ‐ sequela
45
1. C3‐C7 spondylosis with myelopathy
M47.12 Spondylosis with myelopathy
EXERCISES
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 24
2. L4‐L5 spinal stenosis, herniated disc and spondylolisthesis
EXERCISES
M48.06 Stenosis lumbar region
M51.26 Herniated lumbar disc
M43.16 Spondylolisthesis47
3. L4‐L5 spinal stenosis
M48.06 Stenosis lumbar region
EXERCISES
48
2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 25
4. L4‐S1 spinal stenosis
EXERCISES
M48.06 Stenosis lumbar region
M48.07 Stenosis lumbosacral region
Teaching point: 2 diagnoses may be needed ‐ who knows?
49
5. C5‐C6 herniated disc. Radiculopathy
EXERCISES
M50.12 Herniated disc with radiculopathy, mid‐cervical region
Teaching point: ICD‐10‐CM includes specific spinal regions of “high,” “mid” and junctional for some codes.
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 26
6. L5‐S1 herniated disc
M51.27 Other lumbosacral disc displacement
EXERCISES
51
7. L4 radiculopathy
M54.16 Radiculopathy, lumbar
Teaching point: Code did not exist in ICD‐9‐CM.
EXERCISES
52
2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 27
8. Low back pain
M54.5 Lumbago
EXERCISES
53
M71.38 Other bursal cyst, other site
M48.06 Stenosis, lumbar
9. Synovial cyst at L4‐L5. Stenosis at L3‐L5
EXERCISES
54
2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 28
M84.58XA Pathological fracture in other disease, other site
M46.44 Discitis, unspecified, thoracic region
10. Operative note shows the following – Postoperative diagnosis: T4 pathologic fracture secondary to osteodiscitis
EXERCISES
55
M84.58XA Pathologic fracture due to neoplastic disease
C79.51 Vertebral mets
Teaching point: Code also underlying neoplasm.
11. T12 pathologic fracture due to metastatic lung cancer at time of vertebral augmentation procedure
EXERCISES
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 29
12. L4‐L5 osteomyelitis
M46.26 Osteomyelitis of vertebra, lumbar region
EXERCISES
57
13. Pseudoarthrosis L4‐L5
M96.0 Pseudoarthrosis after fusion or arthrodesis
EXERCISES
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2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 30
14. Lumbar instability, lumbar stenosis
1) M53.2X6 Spinal instabilities, lumbar region
2) M48.06 Stenosis, lumbar region
EXERCISES
59
M43.16 Spondylolisthesis, lumbar region
M51.36 Other intervertebral disc degeneration, lumbar region
M48.06 Stenosis, lumbar region
15. Post‐op diagnosis; Spondylolisthesis, grade 1, L4‐L5, degenerative disc disease lumbar spine, spinal stenosis, neural foraminal stenosis, lumbago, sciatica
EXERCISES
60
2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 31
karenzupkoandassociates@KarenZupkoAssocinformation@karenzupko.com
312.642.5616www.karenzupko.comTeri Romano
RN, MBA, CPC, CMDP
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