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S32.000A
ICD-10-CM
Lumbar Spine Compression Fracture

Find information on lumbar spine compression fracture diagnosis, including clinical documentation, medical coding, ICD-10 codes, treatment, and prognosis. Learn about vertebral compression fractures, wedge fractures, burst fractures, and related pain management. Resources for healthcare professionals covering diagnosis, coding guidelines, and documentation best practices for lumbar compression fractures are available. Explore causes, symptoms, and treatment options for compression fractures in the lumbar spine.

Also known as

Vertebral Compression Fracture
Spinal Compression Fracture

Diagnosis Snapshot

Key Facts
  • Definition : Break in a vertebra of the lower back, often causing pain.
  • Clinical Signs : Sudden back pain, limited movement, tenderness to touch, possible deformity.
  • Common Settings : Osteoporosis, trauma (falls, car accidents), cancer spread to the spine.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S32.000A Coding
S32.0-

Fracture of lumbar vertebra

Fractures in the lumbar spine region.

M48.5-

Collapsed vertebra, lumbar

Vertebral compression fractures in the lumbar spine.

M80.-

Osteoporosis with current pathol

Osteoporosis, often a cause of compression fractures.

S22.-

Fracture of thoracic spine

Fractures in the thoracic spine, sometimes relevant.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the fracture traumatic?

  • Yes

    Current encounter for initial fracture?

  • No

    Is the fracture due to osteoporosis?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Lumbar Compression Fracture
Osteoporotic Vertebral Fracture
Thoracic Compression Fracture

Documentation Best Practices

Documentation Checklist
  • Lumbar compression fracture diagnosis ICD-10 code
  • Document mechanism of injury: Fall, trauma, etc.
  • Vertebral level(s) of fracture, using imaging confirmation
  • Pain assessment: Location, severity, type, radiation
  • Neurological exam findings: Sensory, motor, reflexes

Coding and Audit Risks

Common Risks
  • Unspecified Fracture

    Coding unspecified fracture type (e.g., S32.00) when documentation supports a more specific code (e.g., compression fracture).

  • Traumatic vs. Pathologic

    Incorrectly coding a pathologic fracture (M80.-) as traumatic (S32.-) or vice versa without proper documentation of etiology.

  • Documentation Deficiency

    Lacking sufficient documentation to support the diagnosis of a lumbar compression fracture, leading to coding errors or claim denials.

Mitigation Tips

Best Practices
  • ICD-10 M48.4, CDI: Document mechanism of injury for accurate coding.
  • HCC coding: Capture M48.4 for risk adjustment. Review documentation for specificity.
  • Medical necessity: Ensure imaging supports diagnosis and treatment plan. Avoid unnecessary scans.
  • Compliance: Document pain assessment, neurological exam, and treatment rationale.
  • Fall risk assessment: Implement prevention strategies for elderly patients with M48.4.

Clinical Decision Support

Checklist
  • Verify acute back pain onset, consider trauma history (ICD-10 S22, M48.4)
  • Assess for point tenderness, deformity, neurological signs (DOC: Physical Exam)
  • Order imaging: X-ray, CT, or MRI for confirmation (CPT 72100, 72128, 72131)
  • Evaluate osteoporosis risk factors, BMD testing (ICD-10 M80, Z13.82)
  • Consider pain management, bracing, surgery consult (Patient Safety: Fall Risk)

Reimbursement and Quality Metrics

Impact Summary
  • Lumbar Spine Compression Fracture Reimbursement: Coding accuracy impacts MS-DRG assignment affecting hospital payments. Proper ICD-10-CM (e.g., M48.4) and CPT coding crucial for maximizing reimbursement.
  • Quality Metrics Impact: Pain management, functional improvement, and return to activity are key quality metrics. Accurate documentation vital for performance reporting.
  • Coding Accuracy Impact: Incorrect coding (e.g., unspecified fracture) leads to lower reimbursement and potential audits. Specific fracture type (e.g., traumatic vs. pathologic) coding essential.
  • Hospital Reporting Impact: Compression fracture data influences quality scores and resource allocation. Accurate coding and documentation crucial for public reporting and internal analysis.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code vertebral level, type (e.g., wedge)
  • Document mechanism of injury
  • Specify acute vs. chronic fracture
  • Consider osteoporosis coding

Documentation Templates

Patient presents with complaints consistent with lumbar spine compression fracture.  Onset of low back pain is reported as [acute/gradual/insidious], with pain described as [sharp/dull/aching/burning/radiating].  Pain is exacerbated by [movement/flexion/extension/weight-bearing] and alleviated by [rest/ice/heat/medication].  Patient denies [or reports] any history of trauma, osteoporosis, prolonged steroid use, or malignancy.  Physical examination reveals [point tenderness/muscle spasm/limited range of motion/neurological deficits such as decreased sensation, weakness, or diminished reflexes] in the lumbar spine.  Assessment suggests lumbar compression fracture as the likely diagnosis.  Differential diagnoses include lumbar strain, herniated disc, spinal stenosis, and malignancy.  Ordered imaging studies include [X-ray/CT scan/MRI] of the lumbar spine to confirm the diagnosis and assess the severity of the fracture.  Initial treatment plan includes pain management with [analgesics/NSAIDs/opioids if necessary], activity modification, and bracing.  Patient education provided on proper body mechanics, fall prevention strategies, and importance of follow-up care.  Referral to [orthopedics/physical therapy/pain management] will be considered based on imaging results and patient response to initial treatment.  ICD-10 code [S32.0XXA, S32.0XXD, or other appropriate code] is considered based on specific location and type of fracture.  Further evaluation and management will be based on clinical progression and imaging findings.
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