Q&A: Reporting spinal cavernoma in ICD-10-CM

Q: A patient presents with a chief complaint of thoracic intrinsic spinal cord lesion causing back pain, left lower extremity sciatic-type pain, and foot drop. An MRI of the thoracic spine revealed a T11-T12 spinal cord lesion consistent with a cavernous malformation. Which ICD-10-CM codes would be reported?

A: The coder would report this case with ICD-10-CM code Q06.9, Congenital malformation of spinal cord, unspecified.

Cavernous malformations are clusters of abnormal blood vessels that form lesions in the brain or spinal cord. Most cavernous malformations are congenital, but some can develop later in life.

When coding for such malformations, we need to reference the 2024 ICD-10-CM Alphabetic Index, where we will find the following relevant entries under “Malformation”:

• spinal

• cord Q06.9
• nerve root Q07.8

• spine Q76.49

To verify that the code for spinal cord malformation can be reported, we need to refer to the 2024 ICD-10-CM Tabular List, particularly for codes in category Q06.-, Other congenital malformations of spinal cord. These codes—found in Chapter 17—may be used throughout the life of the patient because malformations, deformations, and chromosomal abnormalities, although present at birth, may not be identified until later in life. Per the ICD-10-CM guidelines, Sec.I.C.17, whenever the condition is diagnosed by the provider, coders can assign a code from categories Q00-Q99. This confirms code Q06.9 can be reported.

But the patient also indicated that they were suffering from back pain, sciatic pain in their lower left leg, and foot drop. Do we report any additional codes for these symptoms?

Per the ICD-10-CM guidelines, Sec.I.B.5, conditions that are an integral part of a disease process and “signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.”

Since there was no instruction that the other symptoms were unassociated with the primary diagnosis, we should not report those symptoms with additional codes. Therefore, Q06.9 would be the only diagnosis code reported.

Editor’s note: Adrienne Commeree, RHIA, CPC, CPMA, CCS, CEMC, CPIP, a professor at Tacoma Community College in Tacoma, Washington, answered this question during the HCPro webinar, “2024 ICD-10-CM/PCS Coding: Spinal Diagnoses and Procedures.” This answer was originally published in JustCoding.