Coding of Upper and Mid-Back Pain
Coding of Upper and Mid-Back Pain
Pain in the Upper and/or Mid-back is not as common as neck pain or low back pain, and the more common causes are somewhat different than these others areas as well. Most of the Upper Back Pain is seen in older adults, and results from mostly degenerative processes. Again, as in Neck Pain, this would be considered a Regional Pain for the thoracic spine. There are normally 12 thoracic vertebrae, with the spinal cord contained within the spinal canal, and 12 thoracic nerves on each side. The rib cage, attached to the thoracic spine, provides some support to the thoracic spine unlike the cervical and lumbar regions. The range of motion of the thoracic spine is considerably less by comparison than the cervical and lumbar spine regions. As such, it goes through less wear and tear as a result of spinal movement. The discs in the thoracic region are not as thick or voluminous as those of the lumbar spine below, and as such, disorders of the thoracic discs such as herniation, extrusion, or protrusion are infrequent. However, degeneration of the discs of the thoracic spine does occur along with spondylosis/arthritis of the thoracic spine. Also, in the aging spine, particularly with the presence of Osteoporosis or other bone pathology, atraumatic pathologic fractures and traumatic compression fractures of the thoracic vertebral bodies are more common in this region. One of the main issues in sorting out thoracic spine fractures is what would be considered traumatic versus spontaneous or atraumatic. The question is how much “trauma/stress“ is necessary to result in a fracture over and above that of normal daily activities and motion in the thoracic region. Sometimes, in an elderly patient with significant Osteoporosis something as simple as bending over to pick something light up from the floor is enough to cause a fracture, just as coughing or sneezing hard might cause ribs to fracture. There is a rather fine line between a spontaneous/atraumatic pathologic fracture and the minimum “excess” force/stress resulting from an “injury” to constitute “trauma." Although compression fractures can occur throughout the thoracic spine, they tend to concentrate in the mid and lower thoracic region causing Upper and Mid-back Pain. With multiple compression fractures, older patients can get acquired kyphotic deformities of the upper back (Dowager’s Hump). Another common form of pain in this region is muscular pain and/or spasm from the paraspinal muscles. This can occur as an isolated form of pain, or be a manifestation of some other spinal disorder. In other words, muscles can be the primary pain source, or secondary to something else. Because the posterior ribs attach to, and have joints with the thoracic vertebrae, this would be another possible source of upper back pain. From a chronological point of view, Upper and Mid-back Pain tends to increase in incidence with the aging process of the spine. Pain in this region in growing children and adolescents is generally rare by comparison. Because the paraspinal muscles that support the spine start at the back of the head and go all the way to the sacrum and tailbone region, pain from the neck muscles can radiate or migrate down into the upper back region, commonly between the shoulder blades, or work up from the muscles of the lumbar region into the mid-back region. So sometimes pain in the upper back can be a manifestation of a cervical region disorder, or mid-back pain can be a manifestation of a lumbar spine region disorder. In other words, sometimes the problem can be rather straightforward, or can be quite difficult and complex to diagnose accurately.
In coding for Upper and Mid-back Pain, the “generic code” for this regional pain comes from "Other Dorsopathies,” and in particular from "Dorsalgia (Back Pain)” and is M54.6: Pain in the thoracic spine. Both Upper and Mid-back Pain are covered by this one code, which is only a 4 character code. As for using this code, it is probably valid in and of itself as a “stand alone” code because sometimes there is/are no other more accurate or specific diagnosis(ses) or code(s) that can be used. Sometimes the pain is there without any other clear explanation. However, this code may sometimes need to be supplemented with other code(s) when more than one possible diagnosis or reason for the pain is present. It may take a list of several codes to adequately express all of the possible contributing factors.
Although this discussion is primarily related to the thoracic spine, it has to include the thoracolumbar spine. The thoracolumbar spine is an area of transition between the more stiff and stable thoracic spine and the more mobile and flexible lumbar spine. Also, it is a transition zone from the kyphotic curve of the thoracic spine to the lordotic curve of the lumbar spine. Consequently, it can be an area/segment vulnerable to stresses on the back. Anatomically, this is the T12-L1 junction, but from a more functional or clinical perspective, I would say that the thoracolumbar spine goes from T11 above to the L2 level below. Although there are ribs at T11 and T12, they are not “connected” to the other 10 ribs, and as such do not provide the support, protection, or stability to the T11 and T12 vertebrae spine as the rest of the rib cage does for the other thoracic spine. In discussing Upper and Mid-back Pain, the thoracolumbar region has to be included even though most painful disorders of the thoracolumbar spine will tend to work downward and manifest themselves as lower back pain. From a coding standpoint, when a 5th Character (occasionally 6th Character) is required, 4 is for the thoracic spine, and 5 is for the thoracolumbar spine.
Since the generic code for pain in the thoracic spine (M54.6) is derived from the section of "Other Dorsopathies (M50-M54),” I will review the other codes in this section as they apply to the Upper and mid-back first. The code set M51: Thoracic, thoracolumbar, lumbar, and lumbosacral intervertebral disc orders would be first. This includes intervertebral disc disorders with myelopathy (M51.0), with radiculopathy (M51.1), with displacement (same as rupture, herniation, extrusion, and/or protrusion) (M51.2), disc degeneration (M51.3), and “Other" intervertebral disc disorders (M51.8). For practical purposes, the only one of these that would be considered very common would be intervertebral disc degeneration (M51.34 _). Disc disorders of the thoracic spine rarely cause myelopathy or radiculopathy, and although disc herniations, etc., do occur, they are very infrequent as a diagnosable cause for upper back pain. As for M51.44: “Schmorl's nodes,” although these do occur in the thoracic and lumbar spine regions, they are primarily findings on x-ray studies, and have virtually no clinical importance as to causing back pain. As usual, M51.8: “Other" intervertebral disc disorders would be useful only if there is an identifiable disc lesions not already included/listed, i.e. “none of the above.” Therefore, the only codes from this set that would be of much use would be M51.34 and M51.35 for degenerative disc disease of the thoracic spine, which is common in the older spine, and would usually be an element or associated with spondylosis/arthritis of the spine. Another member of the Other Dorsopathies warranting mention is M54.1: Radiculopathy. However, this Excludes neuralgia and neuritis, and radiculopathy from intervertebral disc disorders and/or from spondylosis. For practical purposes, thoracic radiculopathy or neuritis/radiculitis is extremely rare.
In discussing the Dorsopathies (M40-M54), the first group is the Deforming Dorsopathies (M40-M43), which includes acquired forms of kyphosis, lordosis, and scoliosis, excluding congenital forms, and post-procedural forms. In general, these are not painful disorders until middle or older adulthood, and the pain is mostly the result of secondary arthritis or spondylosis. There is one type of Spinal Osteochondrosis, M42.0: Juvenile Osteochondrosis, which can cause Upper or mostly Mid-back Pain during adolescence. This is Scheurmann's Disease, which is more common in adolescent males, and generally involves the low thoracic and thoracolumbar region of the spine. It can be a cause of pain in these patients. It manifests itself on examination by a “humping" of the back when the patient bends forward and particularly when viewed from the side. The code for this would be M42.0 _. It is caused by an inflammation of the epiphysis (epiphysitis) which results in deformity of the growing vertebral body with anterior wedging and narrowing/compression of the vertebral body. Occasionally, there may be a mild associated scoliosis. As for M42.1: Adult osteochondrosis of the spine, I have never seen this and would not know how to identify it as a clinical condition. As for M43: Other Deforming Dorsopathies, these do not really apply to the thoracic or thoracolumbar spine, even though there are code sets for them.
In the coding section for Spondylopathies (M45-M49), there are definitely portions of this group of codes that could manifest themselves with Upper or Mid-back Pain. Ankylosing Spondylitis (Rheumatoid Arthritis of the Spine) (M45. ) would be one of them. This disorder, however, generally involves the entire spine, usually starting in the low back and sacroiliac regions, then progressing up the spine all the way to the cervical spine. It can cause both back pain and significant deformity of the spine. However, it would be very rare to be isolated to just the thoracic or thoracolumbar spine. The code set M46: Other Inflammatory Spondylopathies also has several possible codings. Spinal Ensethopathy (M46.0) would be a very difficult, distinct diagnosis to make in the thoracic region. I would not know how to diagnose a pain from the ligamentous or muscular attachments of the spine. Osteomyelitis of the vertebrae (M46.2) certainly could happen, but would be rare as an isolated phenomenon, and is far more likely to occur as part of a systemic or multifocal infectious disorder. Pyogenic Discitis (M46.3) would be a rarity, but could occur.. Discitis without an identifiable infectious cause (M46.4) would also be a rare occurrence. "Other" Infectious Spondylopathies (M46.5) would also be a rare diagnosis, and would also only be a part of a more generalized or systemic infectious disease that are not bacterial infections. Other Specified Inflammatory Spondylopathies (M46.8) could apply to such disorders as generalized Rheumatoid Disease, or as a manifestation of other Autoimmune Disorders such as Lupus. Rheumatoid arthritis, in addition to affecting extremity joints, can clearly involve the spine in general, but the cervical spine is the most common and significant region. It might be difficult to isolate the thoracic and/or thoracolumbar regions as a cause of back pain in these disorders. As for Spondylosis (M47), this would be a common cause of Upper and Mid-back Pain due to degeneration of the discs and facet joints. Just like the Intervertebral Disc Disorders previously discussed, although degenerative arthritis of the thoracic spine is common, it rarely causes myelopathy (M47.1), or radiculopathy (M47.2). The codes in M47.8: Other Spondylosis, without myelopathy or radiculopathy, are going to be far more commonly used codes. However, this is a 6 character code, with the 6th Character being 4 for the thoracic region, and 5 for the thoracolumbar region. As regards Other Spondylopathies (M48), there are a couple worthy of mention. Spinal Stenosis of the thoracic and thoracic lumbar spine (M48.0 ) would be very rare as an isolated phenomenon. Ankylosing Hyperostosis (M48.1) is a type of arthritis with significant osteophyte formation from the vertebral bodies, crossing and bridging the discs. It can cause significant limitation of spinal motion as well as pain. The osteophytes bridging a disc may in fact cause spontaneous fusion of the vertebrae. Moreover, this disorder is also just part of a more generalized and comprehensive disorder of the spine rather than being isolated to the thoracic or thoracolumbar segments. I do not think that Kissing Spines (M48.2) probably even occurs in the thoracic region. Traumatic Spondylopathy (M48.3) could be used as a diagnosis code, but I would not use it less the injury is so vague and poorly defined, and/or so remote in the past, that a more clear and accurate diagnosis could not be found and used.
The M48 Code Set: Fatigue/Stress Fracture of the Vertebrae (M48.4) and Collapse/Wedge Compression Fracture of the Vertebrae (M48.5) require a more thorough discussion. It may seem strange, but in actuality, I think these codes have very little use. The reason being is that both of these code sets Exclude pathologic fractures due to neoplasm, other diseases, osteoporosis, and acute traumatic fractures, as well as excluding each other. After considering all of these excluded disorders, we are left with the conclusion that these particular fractures are occurring through basically normal bone. Normal bone does not undergo Atraumatic Stress or Fatigue Fractures, or spontaneous collapse, particularly in the thoracic spine. For practical purposes, Fatigue/Stress and Collapse/Wedge Compression fractures in the thoracic spine only occur through “diseased” bone that makes them too weak to withstand the pressures of normal daily activity. Therefore, when thoracic spine fractures are identified, I would go to the Disorders of Bone Density and Structure (M80-M85) to find the correct code.
M49.8 _: Spondylopathy in Diseases classified elsewhere includes such things as curvature or deformity of the spine such as kyphosis, scoliosis, and spondylopathy in diseases classified elsewhere. In that sense, these codes would apply as a “Secondary Arthritis” of the spine, but the underlying or predisposing disorder also needs to be coded. The 5th Character would be as previously described.
The next category would be Soft Tissue Disorders (M60-M79), and in particular Disorders of Muscles (M60-M63). For these diagnosis codes, the 5th Character would be 8, for Other Sites, which would include the spine. Of these codes, Myositis (M60.) which would include the possibility of an infection (M60.0); Interstitial Myositis, i.e. not infectious (M60.1); and Foreign Body Granuloma of soft tissue (M60.2) could occur. As for the Foreign Body, this could be something like metallic fragments subsequent to a gunshot wound that left residual fragments in the muscles, which could cause muscular inflammation. Calcification or Ossification of the muscles of the thoracic region (M61) would be very rare. Probably the most useful code in this particular group would be M62: Other Disorder of Muscle, which includes M62.830: Muscle Cramp or Spasm of the back muscles. This certainly can occur in the thoracic region, although it tends to be more common in the lower back.
As for Disorders of Synovium and Tendon (M65-M67), I cannot say that any of these would be applicable to the thoracic region.
As for Other Soft Tissue Disorders (M70-M79) the code M70: Soft Tissue Disorders related to use, overuse, and pressure could be useful as it includes occupational disorders. The only useful one that I can see is M70.88 (other site) such as the Upper Back. However, this also needs a Y93 Activity Code if identifiable. In the M79: Other Soft Tissue Disorders NEC, M79.1: Myalgia (Myofascial pain syndrome) could be a useful code. Myalgia simply means muscular ache and/or pain. Many physicians will use the term Myofascial Pain (with or without Syndrome) as a diagnosis, even though it is not really a diagnosis supported by tissue pathology. The term simply refers to pain with tenderness in an area of muscle and the surrounding or covering fascia. It may also be called localized “Fasciitis” or “Fibrositis.” However, it, M79.1, Excludes Fibromyalgia (M79.1). As it relates to the back, this is probably more common in the cervical and upper back and the lower back regions, but could occur in the thoracic region as well. M79.7: Fibromyalgia (also called Fibromyositis, Myofibrositis, and Fibrositis) certainly affects the back and spine region to include the thoracic region, but is not usually isolated to this area, but a part of a more generalized and diffuse disorder. Therefore, these two codes, M79.1 and M79.7, need to be distinguished from each other since there is so much overlapping terminology. M79.1 is a localized disorder, whereas M79.7 is considered a generalized disorder. M79.89: Polyalgia applies to somebody who "hurts all over,” including the upper back.
The next group for discussion would be Osteopathies and Chondropathies (M80-M94), disorders of bone and cartilage as it relates to the thoracic spine region. The first of these would be disorders of Bone Density and Structure (M80-M85). This is a confusing section because it includes Osteoporosis with current pathologic fracture (M80), and without current fracture (M81), as well as other Disorders of the Continuity of Bone (M84) including Stress Fractures (M84.3) and several categories of Pathologic Fractures (M84.4, M84.5, and M84.6). As for Osteoporosis, M80.0 is for Osteoporosis with a current pathologic fracture, and covers Age-related, or what would be considered Primary Osteoporosis, which can go by several other different titles, and M80.8 covers Other Osteoporosis, which would be considered as Secondary Osteoporosis, i.e. resulting from some other disease. M80 Excludes Collapsed Vertebra NOS (M48.5), Pathologic Fracture NOS (M84.4), and Wedging of the Vertebrae NOS (M48.5), which have been previously discussed. The majority of vertebral spine fractures will fall into this group of codes, mostly from the Osteoporosis categories. One of the major problems as was discussed in the introductory portion of this Blog is how much “additional stress” is necessary over and above that of normal daily activities to differentiate a traumatic fracture from an atraumatic fracture resulting from diseased and weakened bone structure. If the patient has a clear history of some identifiable injury or trauma, however minor it might seem to most people, then I would recommend coding it as a Traumatic Fracture (S codes), even though the patient may have some predisposing bone pathology that would make it more susceptible to fracture with a minimal amount of additional stress. To my way of thinking, the codes for M80 and M84, as they apply to the spine, would clearly have to be Spontaneous/Atraumatic. The M80 Code Set requires a 7 Character code, but as it pertains to vertebral fractures there is no laterality, so the 6th Character is X, and the available 7th Characters for use are A, D, G, K, P, or S. The codes for vertebral fractures from M80.0: Age-related Osteoporosis would be M80.08X , and for M80.8: Other Osteoporosis, would be an M80.88X . There is no differentiation as to where in the spine the fracture occurs such as the cervical, thoracic, or lumbar spine regions. The one code applies to all spinal regions.
The M81 Code Set: Osteoporosis without current pathologic fracture is the basic diagnosis coding for Osteoporosis. The 4th Character 0 is for Age-related (Primary) Osteoporosis, 6 is for Localized Osteoporosis, and 8 is for Other (Secondary) Osteoporosis. Osteoporosis, in and of itself, is not a painful disorder. It only becomes painful when something happens such as a vertebral fracture regardless of whether it is traumatic or spontaneous/atraumatic. Considering the age group of patients with Osteoporosis, if they complain of back pain it is most likely from spondylosis/arthritis, with or without a vertebral fracture.
M83: Adult Osteomalacia would be a situation in which the patient has some systemic disease causing “softening of the bones,” which is what osteomalacia means. Without some other complication such as a compression fracture or spinal arthritis, this is also not a painful disorder by itself.
M84: Disorder of Continuity of Bone, as stated above, includes M84.3 for Stress Fracture, M84.4: Pathologic Fracture not elsewhere classified, M84.5: Pathologic Fracture in Neoplastic Disease, and M84.6: Pathologic Fracture in Other Disease(s).
The M84.3: Stress Fracture Code Set Excludes Stress Fracture of the vertebrae (M48.4), which was previously discussed. For practical purposes, M84.3 applies only to Non-Spinal Stress Fractures. The M84.4: Pathologic Fracture not elsewhere classified Excludes Collapsed Vertebra (M48.5), all forms of Pathologic Fractures, Stress Fracture (M84.3), and Traumatic Fractures (S22). The only code in this Code Set that would indicate a vertebral fracture is M84.48X , which requires a 7th Character. M84.5: Pathologic Fracture in Neoplastic Disease, and M84.6: Pathologic Fracture in Other Disease(s) are limited to only 2 codes that pertain to the spine: M84.58X for pathologic neoplastic vertebral fracture, and M84.68X for pathologic vertebral fracture from some other disease. I would recommend using M84.68X only if the “other" disease can be identified, and then it should also be coded.
As for Other Osteopathies (M86-M90), there are not many that pertain to the spine.
M86: Osteomyelitis Excludes osteomyelitis of the vertebrae (M46.2). Only M88.1: Osteitis deformans (Paget’s disease of bone) of the vertebrae could apply to pain in the Upper or Mid-back.
In reviewing the Chondropathies (M91-M94) I do not really find anything in these disorders that would apply to the thoracic spine as a cause of Upper or Mid-back Pain.
The Code Set M96: Intra-operative and Post-procedural Complications and Disorders of the Musculoskeletal System has codes that could pertain to Upper and Mid-back Pain. Any surgical procedure on the spine risks any of the listed complications in this Code Set, which could result in ongoing back pain. However, surgery on the thoracic spine is fairly infrequent when compared to the cervical or lumbar regions.
As for Biomechanical Lesions, not elsewhere classified (M99), these are disorders that could cause Upper and Mid-back Pain if identified. However, these codes should not be used if a more accurate and specific diagnosis can be identified and coded. These are diagnoses that might be identified on either a CT or MRI study. As it pertains to M99.0: Segmental and Somatic Dysfunction, I have no idea what this means, nor how it would be manifested clinically.
As it relates to Congenital Malformations, Deformations, and Chromosomal Abnormalities, Q Codes, there are some possible reasons for Upper Back Pain from these disorders. Most of these would be identified at or soon after birth or in early childhood, and these patients would probably be in the care of Pediatric Orthopedic Surgeons, Neurosurgeons, and/or Spine Surgeons. These would be contained in the code sets for Congenital Malformations of the Nervous System (Q00-Q07) relating to Spina Bifida (Q05), Other Congenital Malformations of the Spinal Cord (Q06) such as Diastematomyelia (Q06.2), and from the Congenital Malformations and Deformities of the Musculoskeletal System (Q65-Q87), in particular Q67: Congenital Musculoskeletal Deformities of the Spine and Chest, and from Q76: Congenital Malformations of the Spine and Bony Thorax. However, unless the patient survives to adulthood, they are not very commonly seen in a general orthopedic surgery practice.
From the R Codes: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, not elsewhere classified (R00-R99) there are no particular codes that are applicable to Upper and Mid-back Pain. R52: Pain, unspecified, should not be used for two reasons: the first being that it is “unspecified,” and because this Code Set Excludes acute and chronic pain NEC (G89) and unspecified localized pain, with a Coding Instruction to Code to pain by site.
As it relates to the G Codes: Diseases of the Nervous System (G00-G99) there are not many that would apply to Upper and Mid-back Pain. In the G54: Nerve Root and Plexus Disorders, there is G54.3: Thoracic root disorder which is not particularly applicable since it has a multitude of Exclusion’s. The same could be said for the code set G55: Nerve root and plexus compressions and diseases classified elsewhere. The codes in Code Set G89: Pain, not elsewhere classified, are not really applicable to the Upper and Mid-back due to the numerous Exclusions, and also it has the Coding Instruction of Code to pain by site. These codes can be used in conjunction with other codes as an adjunct to provide more detail about acute or chronic pain, but only if the pain fits one of the categories of G89.0: Central Pain Syndrome; G89.1 or 8: Acute pain due to trauma (1) or other post-procedural pain (8); G89.21 or 8: Chronic pain due to trauma (1) or other chronic post-procedural pain (8); G89.3: Acute or Chronic Neoplasm related pain; or G89.4: Chronic Pain Syndrome, all of which could include the Upper and Mid-back regions. These codes can also be used to supplement codes from Site of pain codes (M54.6 for the Upper and Mid Back) if they help clarify the pain circumstances, and if the Site of pain code does not adequately describe the severity of the pain. G89 codes can be used as a primary or first listed codes if the Patient Encounter is for Pain Management, not for treatment of the underlying disorder causing the pain. In this circumstance, the G89 code would be listed first, and the code from the underlying disease would be listed second. Also, the G97 Code Set for Intra-operative and post-procedural complications and disorders of the nervous system, not elsewhere classified would be applicable to Upper and Mid-back Pain resulting from the operative complications in the G97.3, G97.4, G97.5, and G97.8 Code Sets. These would relate to thoracic spine procedures of a Neurosurgical or Musculoskeletal nature.
In this Blog, I have gone through all of the various Subsections of ICD-10 that can contain reasons, diagnoses, etc. that can be associated with or manifested by Upper and Mid-back Pain. The Blogs for Neck and Low Back coding will read and be much the same, except for different 5th (or sometimes 6th Characters) for the different spine segments, and some commentary emphasizing those aspects or nuances that are more common to each area.
Posted in Coding Blogs on Aug 16, 2016