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. Author manuscript; available in PMC: 2017 Sep 13.
Published in final edited form as: Spine (Phila Pa 1976). 2012 May 1;37(10):860–874. doi: 10.1097/BRS.0b013e3182376508

Identifying Neck and Back Pain in Administrative Data: Defining the right cohort

Patricia L Sinnott *,, Andrew M Siroka *, Andrea C Shane *, Jodie A Trafton **, Todd H Wagner *
PMCID: PMC5596507  NIHMSID: NIHMS902790  PMID: 22127268

Structured Abstract

Study design

We reviewed existing methods for identifying patients with neck and back pain in administrative data. We compared these methods using data from the Department of Veterans Affairs.

Objective

To answer the following questions: 1) what diagnosis codes should be used to identify patients with neck and back pain in administrative data; 2) because the majority of complaints are characterized as non-specific or mechanical, what diagnosis codes should be used to identify patients with non-specific or mechanical problems in administrative data; and 3) what procedure and surgical codes should be used to identify patients who have undergone a surgical procedure on the neck or back.

Summary of background data

Musculoskeletal neck and back pain are pervasive problems, associated with chronic pain, disability, and high rates of healthcare utilization. Administrative data have been widely used in formative research which has largely relied on the original work of Volinn, Cherkin, Deyo and Einstadter and the Back Pain Patient Outcomes Assessment Team first published in 1992. Significant variation in reports of incidence, prevalence, and morbidity associated with these problems may be due to non standard or conflicting methods to define study cohorts.

Methods

A literature review produced seven methods for identifying neck and back pain in administrative data. These code lists were used to search VA data for patients with back and neck problems, and to further categorize each case by spinal segment involved, as non- specific/mechanical and as surgical or not.

Results

There is considerable overlap in most algorithms. However, gaps remain.

Conclusions

Gaps are evident in existing methods and a new framework to identify patients with neck and back pain in administrative data is proposed.

Keywords: Back pain, Neck pain, Low back pain, Back Pain/epidemiology, Databases, Factual, Disease/classification, Health Services Research


Neck and back pain are highly prevalent problems and administrative data are commonly used to describe the incidence, prevalence, and geographic variation in practice for these conditions.111 This work has largely relied on the methods published in 1992 by Volinn, Cherkin, Deyo and Einstadter and the Back Pain Patient Outcomes Assessment Team (BOAT)12, 13, 14 that identified neck and back pain from ICD-915 codes and used hospitalization as a proxy for morbidity.1214, 16, 17 This original work has led to a broad range of research on neck and back problems using hospital, workers’ compensation and Medicare data. 1825 More recently, the International Society for Pharmacoeconomics and Outcomes Research26 has adopted guidelines for conducting and reviewing research using retrospective administrative databases, but this guideline, while successful in creating an international standard for doing this type research, does not address the idiosyncracies of spine data. With these new guidelines and two decades of changes in medical practice24 as well as a change in focus from analyzing events to evaluating episodes of care,27, 28 a revised methodology may be needed. The purpose of this study was to review methods used to identify patients with neck or back pain in administrative data and, if appropriate, establish a revised framework. Our objective for these analyses was to answer three questions: 1) what diagnosis codes should be used to identify patients with neck and back pain in administrative data; 2) because the majority of complaints are characterized as non-specific or mechanical, what diagnosis codes should be used to distinguish these particular patients in administrative data from patients with more complex problems; and 3) what diagnosis and procedure and surgical codes should be used to identify patients who have undergone surgical or invasive procedures on the neck or back.

Methods

We used a snowball sampling approach to identify algorithms used to identify patients with neck or back pain problems in administrative data. We started by searching the Web of Knowledge (Thomson Reuters Institute for Scientific Information) for articles that referenced Cherkin, Deyo’s 1992 publication.13 Next, we searched PubMed to identify studies that reported using diagnosis or procedure codes to identify these patients in administrative data, using key, words and MeSH terms; we focused on studies written in English. (Search logic is available in Appendix A) These searches plus additional recommendations identified 170 manuscripts for review. We excluded twelve papers based on review of the title (for example, conditions other than neck or back pain) and reviewed 158 abstracts and 48 manuscripts in depth. (APPENDIX B lists the manuscripts reviewed in depth.) Studies were excluded, for example, if they did not include a code algorithm or list 2931, if the study included only a limited number of diagnoses or reported on a limited number of surgical procedures 3239, or if the reports did not involve the use of previously collected administrative data. We additionally excluded studies that were not about neck or back pain, and those studies that used the original Cherkin and Deyo algorithm13, 1823 without modification. This review yielded six papers including Cherkin and Deyo13 that listed diagnosis and procedure-based algorithms for coding neck and back pain (see Table 1).1214, 16, 17, 40,

Table 1.

Comparison of Coding Algorithms

Author. Date Title. Journal Data source Inclusion Exclusions
Cherkin, Deyo, Volinn, Loeser, 1992 Use of the ICD-9-CM to Identify Hospitalizations for Mechanical Low Back Problems in Administrative Databases. Spine National Hospital Discharge Survey Low back (lumbo-sacral spine): Herniated disc; probable degenerative changes; spinal stenosis; possible instability; fractures; nonspecific backache; sequelae of previous surgery and miscellaneous. To identify surgical cases: 03.0;03.09;80.5; 80.50;80.51;80.52; 80.59;81.00;81.06;81.07;81.08 ;81.09;03.6;03.02;78.69 <18 years old Neoplasms Instraspinal abcess; pregnancy; inflammatory spondyloarthropathies, osteomyelitis; open vertebral fractures with and without spinal cord injury, vertebral dislocations; motor vehicle accidents (E800–E849.9); chordotomy (procedure 3.2–03.29); and cervical and thoracic fusions (81.01–81.03).
Volinn, Mayer, Diehr, Van Koevering, Connell, Loeser, 1992 Small Area Analysis for Surgery for Low-Back Pain. Spine Washington State Department of Health data set Low-back: 721.3; 722.10; 722.52; 722.83; 724.2; 724.3; 738.4; 756.11; 756.12; 847.2 and procedure: 03.09; 80.5; 81.06; 81.07; 81.08 Problem other than lumbar; malignancy; trauma; infection stenosis.
Einstadter, Kent, Fihn, Deyo, 1993 Variation in the Rate of Cervical Spine Surgery in Washington State. Medical Care Washington State - Comprehensive Hospital Abstract Reporting System Cervical Spine: Herniated disc; degenerative changes; cervical spine stenosis; possible instability; miscellaneous neck disorders And procedures: 03.0;03.09;80.50;80.51;80.59; 81.00;81.01;81.02;81.08;81.09 ;03.6;03.02(as they pertain to cervical spine procedures) <20 yrs old, neoplasms, spinal infection, acute trauma, inflammatory spondyloarthropathies, congenital anomalies of the cervical spine
Taylor, Anderson, McNeney, Diehr, Lavis, Deyo, Bombardier, Malter, Axcell, 1998 Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State. Health Services Research Canadian Institute for Health Information Database And Washington State - Comprehensive Hospital Abstract Reporting System Neck and Back: Cherkin Deyo for low back and Einstadter for neck. Both Surgical and Non-surgical cases (back = thoraco-lumbar; neck = cervical) Neoplasms (140.0–239.9, 733.1)
Infections (324.1,730.0–730.9)
Inflammatory diseases (720.0–720.9)
Pregnancy related conditions (630.0–676.9) and trauma (805.0–806.9, 839.0–839.5)
Angevine, Arons, McCormick, 2003 National and Regional Variation of Cervical Discectomy with and without anterior fusion 1990–1999. Spine National Hospital Discharge Survey Cervical spine: Own algorithm <15 years old, Exclusions in non-surgical if surgery procedure performed.
Martin, Deyo, Mirza, Turner, Comstock, Hollingsworth, Sullivan, 2008 Expenditures and Health Status Among Adults with Back and Neck Problems. JAMA Medical Expenditure Panel Survey Neck and Back Major codes:720, 721, 722, 723, 724, 737, 805, 806, 839, 846, 847 and their subcodes. <18 yrs; 733.13 pathologic fracture; Mechanical complication of internal orthopedic device, implant and graft; stiffness and arthralgia: because could not distinguish as related to spine or not. No procedure codes because MEPS data insufficient to identify many codes as related to spinal care.
HCUP Back Multiple AHRQ databases Category 205 spondylosis; intervertebral disc disorders; other back problems (includes all spine):720.1, 720.2, 720.81, 720.89, 720.9, 721.0, 721.1, 721.2, 721.3, 721.41, 721.42, 721.5, 721.6,721.7, 721.8, 721.90, 721.91, 722.0 722.10, 722.11, 722.2, 722.30, 722.31, 722.32, 722.39, 722.4, 722.51, 722.52, 722.6, 722.70, 722.71, 722.72, 722.73, 722.80, 722.81, 722.82, 722.83, 722.90, 722.91, 722.92, 722.93, 723.0, 723.1, 723.2, 723.3, 723.4, 723.5, 723.6, 723.7, 723.8, 723.9, 724.00, 724.01, 724.02, 724.09, 724.1, 724.2, 724.3, 724.4, 724.5, 724.6, 724.70, 724.71, 724.79, 724.8, 724.9
HCUP Sprains and Strains Multiple AHRQ databases Category 232 Sprains and strains (pertaining to the spine):840.0, 840.1, 840.2, 840.3, 840.4, 840.5, 840.6, 840.7, 840.8, 840.9, 841.0, 841.1, 841.2, 841.3, 841.8, 841.9, 842.00, 842.01, 842.02, 842.09, 842.10, 842.11, 842.12, 842.13, 842.19, 843.0, 843.1, 843.8, 8439, 844.0, 844.1, 844.2, 844.3, 844.8, 844.9, 845.00, 845.01, 845.02, 845.03, 845, 845.10, 845.11, 845.12, 845.13, 845.19, 846.0, 846.1, 846.2, 846.3, 846.8, 846.9, 847.0, 847.1, 847.2, 847.3, 847.4, 847.9, 848.0, 848.1, 848.2, 848.3, 848.40, 848.41, 848.42, 848.49, 848.5, 848.8, 848.9, 905.7

Angevine et al.17 used the most limited list of diagnoses and procedures to identify care for cervical disc disease. Martin et al.40 had the broadest list of codes to estimate costs of neck and back care using the Medical Expenditure Panel Survey (MEPS). The six studies generally used the same criteria to define non-specific/mechanical neck or back pain, excluding cases with evidence of neoplasm, trauma, inflammatory spondyloarthropathies, and infection or pregnancy. Investigators additionally limited their analyses to adults (exclusion range <15 to < 20 years of age) and clinical conditions (e.g. spinal stenosis, congenital anomalies and pathologic fracture) depending on their data sources and their research questions.

To this list of six papers, we added the AHRQ Healthcare Cost and Utilization Project (HCUP) Clinical Classification Software42 algorithms for “Spondylosis; intervertebral disc disorders; other back problems” (category 205 ) and “Sprains and strains” (category 232). Category 232 - includes all body parts, but we included only those codes that refer specifically to the spine. Between the six papers and two HCUP categories, we had a total of eight coding algorithms. The inclusion and exclusion codes are listed in Appendix C. Because the Cherkin & Deyo paper 13 extended work by Volinn and Loeser,12, 43 we have not incorporated the Volinn list in this table.

These seven algorithms had varying and sometimes conflicting definitions of neck and back pain. Because of this and because current research and clinical practice guidelines differentiate between pain originating in the neck and pain originating in other areas of the spine,44, 45 we standardized our definitions for this project. We adopted the following definitions, consistent with international work9: “spine pain” includes conditions that originate anywhere in the spine; “neck pain” includes conditions that originate in the cervical spine; “back pain” includes conditions originating from the thoracic, lumbar, and sacral spine, including the coccyx; and “low back pain” includes conditions that arise from the lumbar and sacral spine, including the coccyx. 9 These conditions could be “associated with pain as well as causing radicular symptoms from compression or irritation of nerve roots”.13 Non-specific or mechanical spine pain was defined as “without primary neoplastic, infectious, or inflammatory cause” and excluding codes consistent with “pregnancy or major trauma”.13, 16

The algorithms shared many features and their differences were primarily definitional (See Appendix C). Most inclusion and exclusion criteria followed the Cherkin and Deyo13 algorithm, except Taylor, 16 which included thoracic diagnoses in the definition of back and neck problems, and the HCUP back category which included cervical and thoracic diagnoses and the diagnoses pertaining to the coccyx. The most significant differences were between the Cherkin and Deyo13 algorithm, HCUP category 205, and Martin et al.40 In these studies they differed in their definitions of neck vs. back and whether the report was about any neck and back problems, or limited to non-specific problems [e.g. whether to include or exclude ankylosing spondylitis and other inflammatory spondylopathies (720.0 – 720.9), curvatures of the spine, (737.0–737.9), acquired spondylolisthesis and other acquired deformity of the back or spine (738.4–738.5), nonallopathic lesions of the spine (739.1–739.4), anomalies of the spine (756.10–756.2), open or closed spinal fractures with and without mention of spinal cord injury (805 – 806), and other, multiple and ill-defined vertebral dislocations (839.0– 839.5)]. In addition, there are many codes for which the spinal segment is not defined (721.90; 721.91; 722.2; 722.6; 722.70; 722.90; 738.4; and 847.9; 996.4) and were included in both low back and neck pain algorithms. At the end of Appendix C, these non-specific codes and the exclusions due to conditions which were used by Cherkin and Deyo13 to define “non-specific or mechanical low back pain” are included.

To evaluate the differences in these seven algorithms, we used administrative data from the Veterans Health Administration (VA). We identified all patients who received health care services for back or neck problems in fiscal years (FY) 2002 through 2009, analyzing the VA Patient Treatment Files for inpatient utilization and the National Patient Care Database encounter files for outpatient data, using the inclusion diagnosis codes listed in Appendix C. These databases include diagnostic and procedure information for all health care services provided by VA. We searched all available diagnoses in each encounter to identify patients with any spine-related problem. NOTE, in VA up to 20 diagnoses can be included in outpatient data.

To characterize spine conditions as non-specific, we identified the first or incident spine pain event (inpatient admission or outpatient visit or encounter) for each patient in FY2002–2009 VA data, and identified those that would be excluded based on each of the diagnoses included in the “non-specific/mechanical” exclusion list (e.g. pregnancy related or due to infection or trauma). We also identified patients who had undergone a surgical or spinal procedure by procedure code.

Results

We identified 2.77 million unique patients who received care for neck and back problems in VA in fiscal years 2002 – 2009. Tables 2 and 3 demonstrate the results when each selection method was added to the previous algorithm for back pain and neck pain. For example, using the Cherkin and Deyo list alone, 2,129,984 unique individuals with back problems were identified in these data (Table 2). When we add the codes included in the HCUP Back category (205), we identify an additional 33,495 individuals, and when we add the HCUP sprains and strains diagnoses, we identify an additional 3,537 individuals. Finally, when we add the codes from the expanded Martin list another 3,750 individuals are identified. For the most part these differences are definitional, e.g. the Cherkin and Deyo study was about low back pain, which they defined as including thoraco-lumbar, lumbar, lumbo-sacral and sacral symptoms, but not thoracic alone and not coccygeal, while the HCUP back category and the Martin study include all spinal segments. Table 4 demonstrates the number of individuals identified using ICD-9 codes that are not segment specific.

Table 2.

Count of unique patients with back pain: sequential addition of patients by reference

ICD-9 # Back Pain
2009 ICD-9 Code Descriptions
Cherkin & Deyo ‘92 HCUP Back HCUP Sprains & Strains Martin08 Back
720.1 Spinal enthesopathy 271
720.2 Sacroilitis, not elsewhere classified 4,524
721.2 Thoracic spondylosis without myelopathy 10,702
721.3 Lumbosacral spondylosis w/o myelopathy 62,062
721.4 Thoracic or lumbar spondylosis with myelopathy
721.41 Thoracic spondylosis with myelopathy 470
721.42 Lumbar spondylosis w/o myelopathy 1,597
722.10 Displacement of lumbar inter-vertebral disc w/o myelopathy 16,616
722.1 Displacement of thoracic or lumbar inter-vertebral disc w/o myelopathy
722.11 Displacement thoracic intervertebral disc without myelopathy 702
722.31 Schmorl’s nodes-thoracic region 71
722.32 Schmorl’s nodes lumbar region 161
722.5 Degeneration of thoracic or lumbar intervertebral disc
722.51 Degeneration of thoracic or thoracolumbar intervertebral disc 4,930
722.52 Degeneration of lumbar or lumbosacral intervertebral disc 84,079
722.72 Intervertebral disc disorder with myelopathy-thoracic region 215
722.73 Intervertebral disc disorder with myelopathy, lumbar region 1,837
722.82 Postlaminectomy syndrome-thoracic region 85
722.83 Postlaminectomy syndrome lumbar region 2,881
722.92 Other and unspecified disc disorder-thoracic region 941
722.93 Other and unspecified disc disorder, lumbar region 7,040
724.00 Spinal stenosis - unspecified region 26,837
724.0 Spinal stenosis, other than cervical
724.01 Spinal stenosis, other than cervical-thoracic region 621
724.02 Spinal stenosis, other than cervical-lumbar region 36,867
724.09 Spinal stenosis, other than cervical-other 1,674
724.1 Pain in thoracic spine 13,312
724.2 Lumbago 1,227,654
724.3 Sciatica 74,352
724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 51,918
724.5 Backache, unspecified 504,854
724.6 Disorders of sacrum 2,862
724.70 Unspecified disorder of coccyx 446
724.7 Disorders of the coccyx
724.71 Hypermobility of coccyx 20
724.79 Disorders of coccyx-other 4,062
724.8 Other symptoms referable to back 8,741
724.9 Other unspecified back disorders 30,226
737.0 Adolescent postural kyphosis 28
737.10 Kyphosis (acquired)(postural) 7,684
737.1 Kyphosis acquired
737.11 Kyphosis due to radiation 15
737.2 Lordosis (acquired)
737.20 Lordosis (acquired)(postural) 586
737.21 Lordosis, postlaminestomy 5
737.22 Other post surgical lordosis 4
737.29 Lordosis acquired other 97
737.34 Thoracogenic scoliosis 679
737.41 Curvature of the spine associated with other conditions, kyphosis 273
737.42 Curvature of the spine associated with other conditions, Lordosis 26
738.4 Acquired spondylolisthesis 2,526
739.2 Nonallopathic lesions, thoracic region
739.3 Nonallopathic lesions, lumbar region 1,573
739.4 Nonallopathic lesions, sacral region 828
756.11 Spondylolysis, lumbosacral region 1,535
805.2 Thoracic fracture, closed, without mention of spinal cord injury 2,499
805.3 Thoracic fracture, open, without mention of spinal cord injury 23
805.4 Lumbar fracture, closed, without mention of spinal cord injury 4,157
805.5 Lumbar fracture, open, without mention of spinal cord injury 42
805.6 Sacrum and coccyx fracture, closed, without mention of spinal cord injury 516
805.7 Sacrum and coccyx fracture, open, without mention of spinal cord injury 17
806.2 Thoracic fracture, closed with spinal cord injury
806.3 Thoracic fracture, open with spinal cord injury
806.4 Lumbar fracture, closed with spinal cord injury 413
806.5 Lumbar fracture, open with spinal cord injury 39
806.6 Sacrum and coccyx fracture, closed with spinal cord injury
806.7 Sacrum and coccyx fracture, open with spinal cord injury
839.2–839.21 Other, multiple, and ill-defined vertebral dislocations, thoracic and lumbar vertebra, closed 83
839.3–839.31 Other, multiple, and ill-defined vertebral dislocations, thoracic and lumbar vertebra, open 2
846.0 Sprains and strains of the lumbosacral (joint) (ligament) 6,317
846 Sprains and strains of sacroiliac region
846.1 Sacroiliac ligament 724
846.2 Sacrospinatus (ligament) 15
846.3 Sacrotuberous (ligament) 6
846.8 Other specified sites of sacroiliac region 135
846.9 Unspecified site of sacroiliac region 2,648
847.1 Sprains and strains of other and unspecified parts of back-thoracic 3,704
847.2 Sprains and strains of other and unspecified parts of back-lumbar 22,377
847.3 Sprains and strains of other and unspecified parts of back-sacrum 253
847.4 Sprains and strains of other and unspecified parts of back-coccyx 534
Unique Individuals 2,129,984 33,495 3,537 3,750

Table 3.

Count of unique patients with neck pain: sequential addition of patients by reference

ICD-9 # Neck Pain
2009 ICD-9 Code Descriptions
Einst93 Angevine ‘03 HCUP Back HCUP Sprains & Strains Martin08
721.0 Cervical spondylosis without myelopathy 51,201
721.1 Cervical spondylosis with myelopathy 8,898
722.0 Displacement of cervical intervertebral disc without myelopathy 8,129
722.4 Degeneration of cervical intervertebral disc 36,439
722.71 Intervertebral disc disorder with myelopathy-cervical region 2,921
722.81 Postlaminectomy syndrome-cervical region 737
722.91 Other and unspecified disc disorder-cervical region 4,592
723.0 Spinal stenosis of cervical region 15,940
723 Other disorders of the cervical region
723.1 Cervicalgia 305,163
723.2 Cervico-cranial syndrome 197
723.3 Cervicobrachial syndrome (diffuse) 1,239
723.4 Brachial neuritis or radiculitis 49,032
723.5 Torticollis, unspecified 5,078
723.6 Panniculitis specified as affecting neck 29
723.7 Ossification of posterior longitudinal ligament in cervical region 59
723.8 Other syndromes affecting cervical region 5,422
723.9 Unspecified musculoskeletal disorders and symptoms referable to neck 2,952
738.2 Acquired deformity of the neck
739.1 Non allopathic lesions cervical 1,550
805.0 Closed cervical vertebral fractures without mention of spinal cord injury
805.1 Cervical fracture, open, without mention of spinal cord injury
806.0 – 806.09 Cervical fracture, closed with spinal cord injury 57
806.1–806.19 Cervical fracture, open with spinal cord injury 2
839.0–839.08 Multiple ill defined dislocations of the cervical vertebra, closed 80
839.1–839.18 Multiple ill defined dislocations of the cervical vertebra, open 2
847.0 Sprains and strains of other and unspecified parts of back-neck 18,993
Unique Individuals 503,694 27 36

Table 4.

Count of patients identified by codes that are not specific to spinal segment

ICD-9 # Segment not specific
2009 ICD-9 Code Descriptions
Cherkin & Deyo ‘92 HCUP Back HCUP Sprains & Strains Martin08 Back
307.89 Psychogenic back pain 14,407
720 Ankylosing spondylitis and other inflammatory spondylopathies
720 Ankylosing spondylitis 8,260
720.8 Other inflammatory spondylopathies
720.81 Other inflammatory spondylopathies in diseases classified elsewhere 296
720.89 Other inflammatory spondylopathies - other 243
720.9 Unspecified inflammatory spondylopathy 1,127
721 Spondylosis and allied disorders
721.5 Spondylosis and allied disorders - Kissing Spine 60
721.6 Spondylosis and allied disorders - Ankylosing vertebral hyperostosis 433
721.7 Traumatic spondylopathy 245
721.8 Other allied disorders of the spine 4,645
721.9 Spondylosis of unspecified site without mention of myelopathy 36,692
721.9 Spondylosis of unspecified site
721.91 Spondylosis of unspecified site with myelopathy 331
722 Intervertebral disc disorders
722.2 Displacement of intervertebral disc, site unspecified, w/o myelopathy 12,003
722.3 Schmorl’s nodes-unspecified region 51
722.3 Schmorl’s nodes 27
722.39 Schmorl’s nodes-other 20
722.6 Degeneration of intervertebral disc site unspecified 57,671
722.7 Intervertebral disc disorder with myelopathy-unspecified region 191
722.7 Intervertebral disc disorder with myelopathy
722.8 Postlaminectomy syndrome-unspecified region 520
722.8 Postlaminectomy syndrome
722.9 Other and unspecified disc disorder-unspecified region 5,011
722.9 Other and unspecified disc disorder site unspecified
724 Other and unspecified disorder of back
737 Curvature of the spine
737.12 Kyphosis, postlaminectomy 10
737.19 Kyphosis acquired-other 959
737.3 Scoliosis [and kyphoscoliosis], idiopathic 13,900
737.3 Kyphoscoliosis and scoliosis
737.31 Resolving infantile idiopathic scoliosis 11
737.32 Progressive infantile idiopathic scoliosis 2
737.33 Scoliosis due to radiation 4
737.39 Other kyphoscoliosis and scoliosis 1,633
737.4 Curvature of the spine associated with other conditions
737.4 Curvature of the spine associated with other conditions, unspecified 80
737.43 Curvature of the spine associated with other conditions, Scoliosis 362
737.8 Other curvatures of the spine 96
737.9 Unspecified curvature of the spine 368
738.5 Other acquired deformity of the back or spine 609
756.1 Anomaly of spine, unspecified
756.12 Spondylolisthesis 3,951
756.13 Congenital anomalies of the spine - absence of a vertebra 11
756.14 Congenital anomalies of the spine - hemivertebra 4
756.15 Congenital anomalies of the spine - congenital fusion of the vertebrae 290
756.16 Congenital anomalies of the spine - Klippel-feil 26
756.17 Congenital anomalies of the spine - spina bifida occulta 489
756.18 Congenital anomalies of the spine
756.19 Congenital anomalies of the spine - other 883
805 Fracture of vertebral column without mention of spinal cord injury
805.8 Vertebral fractures, unspecified closed, without mention of spinal cord injury 4,382
805.9 Vertebral fractures, unspecified open, without mention of spinal cord injury 23
806 Fracture of vertebral column with spinal cord injury
806.8 Vertebral fractures, unspecified closed with spinal cord injury 116
806.9 Vertebral fractures, unspecified open with spinal cord injury 20
839.4–839.49 Other, multiple, and ill-defined vertebral dislocations, other vertebra, closed 202
839.5–839.59 Other, multiple, and ill-defined vertebral dislocations, other vertebra, open 1
847 Sprains and strains of other and unspecified parts of back
847.9 Sprains and strains of other and unspecified parts of back-unspecified 41,151
996.4 Mechanical complication of internal orthopedic device, implant and graft 5,405
Unique Individuals* 204,357 1,686 0 11,178
*

Not a column sum

Because several of the codes that were not spinal segment specific were included in both neck pain and back pain algorithms, we continued the analyses to further define whether a patient had neck pain or back pain. We selected those cases in which a code referring to a non-specific spinal segment had served to identify the case for the cohort (e.g. in the incident event in these data) and searched for additional segment-specific codes in the first and subsequent encounters. (Table 5) We found that approximately 75 per cent of all cases included diagnoses referring to the back only, and 15 per cent referred to the neck only. The remaining 10 per cent included more than one area of the spine or combinations of codes for neck, back and non specific parts of the spine. Approximately 6.5 percent of cases included only non-specific codes.

Table 5.

Count of patients by spinal segment diagnoses

Group Patients
Back only 2,067,504
Neck only 420,745
Segment not-specified only 181,900
Back and Neck 76,363
Back and not-specified 25,566
Neck and not-specified 5,128
Back, Neck, and not-specified 1,914
Total 2,779,120

Next, using the Cherkin and Deyo13 definitions, to identify patients with non-specific neck or low back pain, we excluded those cases “with a primary neoplastic, infectious, or inflammatory cause” and those “associated with pregnancy or major trauma”.13, 16 We identified the number of cases to be excluded if one of these conditions appeared in the data within one year prior to the first neck or back problem, and any years after. (Table 6) We included, “any years after” in order to control for potential prodromal conditions unidentified at first onset of the spine problem. Next, we examined the neoplasm exclusions. We hypothesized that, because diagnoses of primary skin and prostate cancers are common but rarely contribute to spine pain, and are either acutely treatable or slow-growing, asymptomatic, and non-metastatic, we removed the diagnoses for primary skin cancers (ICD-9 173.–173.9) and primary prostate cancer (ICD-9-185) from the exclusion list (NOTE exclusion of secondary malignant neoplasms - e.g. ICD codes 196–239.9- served to exclude those patients with cases of skin or prostate cancer that had advanced beyond the primary site). This served to reduce the number of cases excluded from the first step by 15 percent (from 1,000,709 cases excluded to 853,615 cases excluded). Also because administrative data that reflects health care encounters to “rule out” a diagnosis might include the diagnosis to be “ruled out”, we then demonstrated this potential effect by requiring each of the exclusionary conditions to appear in the data two or more times within 12 months46. (Table 6) This second method reduced the number of cases to exclude due to pregnancy more than 83 percent, the number due to intraspinal abcess (324.1) and osteomyelitis, etc. (730.07–730.99) by approximately 45 per cent, and the number due to neoplasm (not including primary skin and prostate cancer) by one-third.

Table 6.

Defining non-specific/mechanical back or neck pain (any occurrence by ICD-9 code, not sequential exclusion)

ICD-9 # 2009 ICD 9 Code Descriptions Patients excluded with one encounter Patients excluded with neoplasm list restricted Patients excluded with two encounters Patients excluded with two encounters: neoplasm restricted
324.1 Intraspinal abscess 1,613 1,613 884 884
733.1 Pathologic fracture 0 0 0 0
03.2 – 03.29 Chordotomy 115 115 3 3
140–239.99 Neoplasm all inclusive 1,000,709 --- 715,351 ---
173.0 – 173.9 Neoplasm of the skin --- 154,456 --- 99,521
185–185.9 Neoplasm of the prostate gland --- 182,789 --- 151,912
140–239.99 Neoplasm (not including primary neoplasm of the skin or prostate gland) --- 853,615 --- 555,314
630–676.9 Pregnancy 14,787 14,787 2,482 2,482
730.0–730.99 Osteomyelitis, periostitis, and other infections involving bone 36,417 36,417 20,306 20,306
805 – 806 Vertebral fractures 18,611 18,611 1,040 1,040
E800–E849 Transportation Accidents 162,590 162,590 47,137 47,137
Unique Individuals potentially excluded* 1,116,224 979,772 760,217 604,305
*

Not a column sum

We next reviewed the algorithms used by the authors above 13, 14, 16, 17 to characterize hospitalizations as surgical and non-surgical, and these were straightforward. In these studies, once the spinal segment and the inclusion diagnoses had been defined, surgical and non-surgical hospitalizations were defined by the presence or not, of a limited list of ICD-9 surgery codes for spinal canal decompression, laminectomy, discectomy, fusion and refusion (ICD-9 codes 03.0, 03.02, 03.09, 03.6, 80.5, 80.50–80.52, 80.59, 81.0, 81.00–81.08, 81.3–81.39), excision of bone for graft (77.70 and 77.79) and insertion or removal of an internal fixation device or bone growth stimulator (78.50, 78.59, 78.60,78.69, 78.90,78.99). Because of changes in medical practice, and because some of these procedures might more recently be performed in an outpatient setting, we added appropriate CPT codes to this surgery list (CPT Surgery/Musculoskeletal System/Spine (Vertebral Column) CPT 22100–22865 and 62263 – 63710). We found that using the ICD codes alone we identified 36,724 patients who had undergone one of the spinal surgeries identified above, and adding the CPT codes, we identified a total of 46,615 patients, a 27% increase in the number of patients identified as having undergone a surgery or procedure. (See Appendix D for detail).

Discussion

We identified five papers published since Cherkin and Deyo13 that defined algorithms to identify patients with neck or back pain in administrative data. These methods, for the most part, are based on the algorithms developed by the Back Pain Outcomes Assessment Team (BOAT) for the study of back and neck pain.13, 14, 17 modified to address the questions of individual researchers. We found that there was overlap in the definitions of neck and back conditions and that it was necessary to clarify which spinal segments were included in each classification. In addition, we found that more than 204,000 cases in our 2002 – 2009 population were assigned a diagnosis in the first encounter that was not spinal segment specific, thus requiring additional analyses to specify the appropriate spinal segment.

We found consistency in the definitions of mechanical or non-specific spine pain (exclusion of neoplasm, infectious or inflammatory causes, pregnancy, trauma, etc.) and that requiring confirmation of an exclusionary diagnosis with a second encounter with that diagnosis reduced the number of cases excluded by 32–38 percent. We also determined that removing primary skin and prostate cancers from the neoplasm exclusions reduced the number of cases excluded by 147,094 individuals (14.7%). Finally, we determined that the addition of procedure codes to surgery algorithms had the potential to identify many more cases (in this case 275 more cases) to consider when analyzing surgery in more recent data.

Our findings suggest that, rather than code lists, the research community should adopt important technical guidelines for use in studies of neck and back pain using retrospective databases. 26 First, in order to enhance utility and comparability of results9, researchers should specify the focus of their research using anatomical references to describe neck and back pain. Second, if the researchers plan to include diagnosis codes that are not spine segment specific (e.g. ICD codes 721.90; 721.91; 722.2; 722.6; 722.70; 722.90; 738.4; and 847.9) they should confirm that these non-specific codes are associated with their segments of interest with additional exploration of the data.(For example, if the code used to select a patient is 721.9, spondylosis of unspecified site without mention of myelopathy, then the researcher should search forward in the data to determine if the preponderance of data reflected a neck or back condition.) Third, researchers should consider whether exclusionary diagnoses should be confirmed with at least two encounters and whether common conditions that rarely have impact on spine pain (for example, primary skin and prostate cancer) should be removed from exclusion lists. Fourth, researchers should use relevant diagnosis and procedure and surgery codes and both inpatient and outpatient data to identify the population of patients who receive spine related surgery and procedures. Additionally, to enhance comparability, researchers should report if they exclude any of the following conditions from their cohort: ankylosing spondylitis, etc (720.0–720.9); curvatures of the spine (737.0 – 737.9, excludes congenital); acquired spondylolisthesis and other acquired deformity of the back or spine (738.4–738.5); nonallopathic lesions of the spine (739.1–739.4); anomalies of the spine (756.10–756.2); open/closed spinal fractures (805.0–806.9); and other vertebral dislocations (839.0–839.5). Finally, the research community should determine whether the above diagnostic groups should be included or excluded in analyses and reports of non-specific neck or back problems.

This study has several strengths that suggest that these recommendations will improve the validity and generalizability of studies which use this revised framework. First, the literature review identified 48 studies that reported using diagnosis and procedure codes to identify patients with neck and back conditions in administrative data. While the majority of these studies relied on the original algorithms developed by Cherkin and Deyo and the BOAT research group,13 consolidating the code list into a single table served to highlight the patterns of inclusion, exclusion and omission specific to each algorithm. This has provided an introduction to the scope of variation to be considered in defining a new framework. Second, we have tested these algorithms and assumptions in an extremely large administrative database. VA has been using an electronic health record for over ten years, and national compilations of longitudinal data have been used in this study. VA administrative data is comprehensive and includes inpatient, outpatient, ancillary and pharmaceutical care for a large population of Veterans (each year +/− 5 million Veterans receive health care services through the Veterans Health Administration). In addition, VA administrative data is routinely used to assess the quality and timeliness of care provided in VHA, and has been a primary resource for VA quality, safety and outcomes research.26, 4749 As a result, testing the algorithms on such a large data set is unlikely to miss any important trends that might be present in smaller patient populations. Third, diagnosis and procedural coding activities are highly automated and professionalized in VA. This expertise is demonstrated in the frequency reports (Tables 2, 3 and 4) in which, as per correct coding conventions defined by the American Hospital Association, American Medical Association, the Centers for Medicare and Medicaid Services, and the National Center for Health Statistics, no patients are identified with three digit major codes, and no patients were identified with four digit subcodes if there was a five digit code available for more specificity (see Table 2, ICD-9 722.5, 722.51, 722.52). In VA, coding rules are integrated into the electronic data capture and all inpatient coding is done by credentialed experts. In practical terms, this means that diagnosis and procedure codes entered into the administrative data represent, in the most accurate way possible, the diagnoses, services and procedures received by an individual patient. In some cases, however, the professionalism in coding practice may also be a limitation, as it may not accurately reflect the errors produced in other environments where data entry is not automated or done by expert coders (for example see Stano and Smith).50 Only further research can confirm what errors occur and what methods should be used for correction.

Our review of the algorithms used to identify patients with neck and back problems in administrative data suggest that an update to the most commonly used algorithm is warranted. This new methodology would have the researcher use international standards9 to define the spinal segment(s) of interest, confirm anatomical references when including diagnosis codes that are not segment specific, confirm the presence of excluding diagnoses in more than a single encounter of care, and would define surgical patients using both surgical and procedure codes from both inpatient and outpatient events of interest. This new framework also includes the recommendation for specificity in reporting on the spinal segment of interest and the conditions to be included and excluded from the analyses. This methodology is not limited to the use of CPT and ICD9 codes but is appropriate for use in any epidemiological or health services research which uses administrative data for the study of neck and back pain conditions. With such a standardized methodology and reporting format, methodological variation in reports of the incidence, prevalence and outcomes of care can be minimized.

Key Points.

  • Methods for identifying patients with neck and back problems in administrative data have not kept pace with changes in practice and coding.

  • A review of current methods suggests a new framework for identifying patients with neck and back pain in administrative data.

  • An updated framework to identify patients with neck and back pain in administrative data will help capture more cases for analyses.

Acknowledgments

Funding for this study was provided by the VA Health Services Research and Development Service (HSR&D IIR 09-062) and was approved by the Stanford IRB and the VA Palo Alto Health Care Research and Development program.

Appendix A: Pubmed Search Logic

Back and International Classification of Disease (ICD) and epidemiology; Neck and ICD and epidemiology; Back and ICD and surgery; Neck and ICD and surgery; Back and Common Procedure Terminology (CPT) and epidemiology; Neck and CPT and epidemiology; Back and CPT and surgery; and Neck and CPT and surgery. In addition we performed a search using a consolidation of the previous logic: ((“back pain”[MeSH Terms] OR (“back”[All Fields] AND “pain”[All Fields]) OR “back pain”[All Fields]) OR (“low back pain”[MeSH Terms] OR (“low”[All Fields] AND “back”[All Fields] AND “pain”[All Fields]) OR “low back pain”[All Fields]) OR (“neck pain”[MeSH Terms] OR (“neck”[All Fields] AND “pain”[All Fields]) OR “neck pain”[All Fields])) AND (cpt[All Fields] OR (common[All Fields] AND procedural[All Fields] AND terminology[All Fields]) OR icd[All Fields] OR icd9[All Fields] OR (international classification of diseases[All Fields] OR international classification of diseases/classification[All Fields] OR international classification of diseases/economics[All Fields] OR international classification of diseases/history[All Fields] OR international classification of diseases/instrumentation[All Fields] OR international classification of diseases/standards[All Fields] OR international classification of diseases/trends[All Fields] OR international classification of diseases/utilization[All Fields])) AND ((“surgery”[Subheading] OR “surgery”[All Fields] OR “surgical procedures, operative”[MeSH Terms] OR (“surgical”[All Fields] AND “procedures”[All Fields] AND “operative”[All Fields]) OR “operative surgical procedures”[All Fields] OR “surgery”[All Fields] OR “general surgery”[MeSH Terms] OR (“general”[All Fields] AND “surgery”[All Fields]) OR “general surgery”[All Fields]) OR (“epidemiology”[Subheading] OR “epidemiology”[All Fields] OR “prevalence”[All Fields] OR “prevalence”[MeSH Terms])

APPENDIX B

Manuscripts reviewed in depth:

  1. Cherkin DC, Deyo RA, Volinn E, Loeser JD. Use of the International Classification of Diseases (ICD-9-CM) to identify hospitalizations for mechanical low back problems in administrative databases. Spine. 1992;17(7):817–825.

  2. Dasinger LK, Krause N, Deegan LJ, Brand RJ, Rudolph L. Duration of work disability after low back injury: a comparison of administrative and self-reported outcomes. Am J Ind Med. 1999;35(6):619–631.

  3. Dasinger LK, Krause N, Deegan LJ, Brand RJ, Rudolph L. Physical workplace factors and return to work after compensated low back injury: a disability phase-specific analysis. J Occup Environ Med. 2000;42(3):323–333.

  4. Dasinger LK, Krause N, Thompson PJ, Brand RJ, Rudolph L. Doctor proactive communication, return-to-work recommendation, and duration of disability after a workers’ compensation low back injury. J Occup Environ Med. Jun 2001;43(6):515–525.

  5. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. Apr 7 2010;303(13):1259–1265.

  6. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. Jun 1992;45(6):613–619.

  7. Einstadter D, Kent DL, Fihn SD, Deyo RA. Variation in the rate of cervical spine surgery in Washington State. Med Care. Aug 1993;31(8):711–718.

  8. Elam K, Taylor V, Ciol MA, Franklin GM, Deyo RA. Impact of a worker’s compensation practice guideline on lumbar spine fusion in Washington State. Med Care. May 1997;35(5):417–424.

  9. Faciszewski T, Jensen R, Berg RL. Procedural coding of spinal surgeries (CPT-4 versus ICD-9-CM) and decisions regarding standards: a multicenter study. Spine (Phila Pa 1976). Mar 1 2003;28(5):502–507.

  10. Fishman P, Von Korff M, Lozano P, Hecht J. Chronic care costs in managed care. Health Aff (Millwood). May-Jun 1997;16(3):239–247.

  11. Krause N, Dasinger LK, Deegan LJ, Brand RJ, Rudolph L. Alternative approaches for measuring duration of work disability after low back injury based on administrative workers’ compensation data. Am J Ind Med. 1999;35(6):604–618.

  12. Lavis JN, Malter A, Anderson GM, et al. Trends in hospital use for mechanical neck and back problems in Ontario and the United States: discretionary care in different health care systems. CMAJ. Jan 13 1998;158(1):29–36.

  13. Lipscomb HJ, Cameron W, Silverstein B. Back injuries among union carpenters in Washington State, 1989–2003. Am J Ind Med. Jun 2008;51(6):463–474.

  14. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. Feb 13 2008;299(6):656–664.

  15. Martin BI, Turner JA, Mirza SK, Lee MJ, Comstock BA, Deyo RA. Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997–2006. Spine (Phila Pa 1976). Sep 1 2009;34(19):2077–2084.

  16. Nilasena DS, Vaughn RJ, Mori M, Lyon JL. Surgical trends in the treatment of diseases of the lumbar spine in Utah’s Medicare population, 1984 to 1990. Med Care. Jun 1995;33(6):585–597.

  17. Nimgade A, McNeely E, Milton D, Celona J. Increased expenditures for other health conditions after an incident of low back pain. Spine (Phila Pa 1976). Apr 1 2010;35(7):769–777.

  18. Phibbs CS, Bhandari A, Yu W, Barnett PG. Estimating the costs of VA ambulatory care. Med Care Res Rev. Sep 2003;60(3 Suppl):54S–73S.

  19. Ray GT, Collin F, Lieu T, et al. The cost of health conditions in a health maintenance organization. Med Care Res Rev. Mar 2000;57(1):92–109.

  20. Romano PS, Campa DR, Rainwater JA. Elective cervical discectomy in California: postoperative in-hospital complications and their risk factors. Spine (Phila Pa 1976). Nov 15 1997;22(22):2677–2692.

  21. Stano M, Smith M. Chiropractic and medical costs of low back care. Med Care. Mar 1996;34(3):191–204.

  22. Steenstra IA, Verbeek JH, Prinsze FJ, Knol DL. Changes in the incidence of occupational disability as a result of back and neck pain in the Netherlands. BMC Public Health. 2006;6:190.

  23. Taylor VM, Anderson GM, McNeney B, et al. Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State. Health Serv Res. Oct 1998;33(4 Pt 1):929–945.

  24. Van Eerd D, Cote P, Beaton D, Hogg-Johnson S, Vidmar M, Kristman V. Capturing cases in workers’ compensation databases: the example of neck pain. Am J Ind Med. Jul 2006;49(7):557–568.

  25. Vogt MT, Kwoh CK, Cope DK, Osial TA, Culyba M, Starz TW. Analgesic usage for low back pain: impact on health care costs and service use. Spine (Phila Pa 1976). May 1 2005;30(9):1075–1081.

  26. Volinn E, Mayer J, Diehr P, Van Koevering D, Connell FA, Loeser JD. Small area analysis of surgery for low-back pain. Spine (Phila Pa 1976). May 1992;17(5):575–581.

  27. Wang MC, Chan L, Maiman DJ, Kreuter W, Deyo RA. Complications and mortality associated with cervical spine surgery for degenerative disease in the United States. Spine (Phila Pa 1976). Feb 1 2007;32(3):342–347.

  28. Wang MC, Laud PW, Macias M, Nattinger AB. Utility of a Combined CPT and ICD9-CM Code Algorithm in Classifying Cervical Spine Surgery for Degenerative Changes. Spine (Phila Pa 1976). Jan 17 2011.

  29. Wang MC, Kreuter W, Wolfla CE, Maiman DJ, Deyo RA. Trends and variations in cervical spine surgery in the United States: Medicare beneficiaries, 1992 to 2005. Spine (Phila Pa 1976). Apr 20 2009;34(9):955–961; discussion 962–953.

  30. Wang MC, Laud PW, Macias M, Nattinger AB. Strengths and limitations of International Classification of Disease Ninth Revision Clinical Modification codes in defining cervical spine surgery. Spine (Phila Pa 1976). Jan 1 2011;36(1):E38–44.

  31. Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine. Nov 1 2006;31(23):2707–2714.

  32. Baaj AA, Uribe JS, Nichols TA, et al. Health care burden of cervical spine fractures in the United States: analysis of a nationwide database over a 10-year period. J Neurosurg Spine. Jul 2010;13(1):61–66.

  33. Bener A, Rahman YS, Mitra B. Incidence and severity of head and neck injuries in victims of road traffic crashes: In an economically developed country. Int Emerg Nurs. Jan 2009;17(1):52–59.

  34. Besman A, Kaban J, Jacobs L, Jacobs LM. False-negative plain cervical spine x-rays in blunt trauma. Am Surg. Nov 2003;69(11):1010–1014.

  35. Bourbeau R, Desjardins D, Maag U, Laberge-Nadeau C. Neck injuries among belted and unbelted occupants of the front seat of cars. J Trauma. Nov 1993;35(5):794–799.

  36. Brolin K, von Holst H. Cervical injuries in Sweden, a national survey of patient data from 1987 to 1999. Inj Control Saf Promot. Mar 2002;9(1):40–52.

  37. Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma. May 2005;58(5):890–895; discussion 895–896.

  38. Campbell PG, Malone J, Yadla S, et al. Comparison of ICD-9-based, retrospective, and prospective assessments of perioperative complications: assessment of accuracy in reporting. J Neurosurg Spine. Jan 2010;14(1):16–22.

  39. Cimmino MA, Ugolini D, Cauli A, et al. Frequency of musculoskeletal conditions among patients referred to Italian tertiary rheumatological centers. Clin Exp Rheumatol. Nov–Dec 2006;24(6):670–676.

  40. Daniels AH, Arthur M, Hart RA. Variability in rates of arthrodesis for patients with thoracolumbar spine fractures with and without associated neurologic injury. Spine (Phila Pa 1976). Oct 1 2007;32(21):2334–2338.

  41. Dunning KK, Davis KG, Cook C, et al. Costs by industry and diagnosis among musculoskeletal claims in a state workers compensation system: 1999–2004. Am J Ind Med. Mar 2009;53(3):276–284.

  42. Hu RW, Jaglal S, Axcell T, Anderson G. A population-based study of reoperations after back surgery. Spine (Phila Pa 1976). Oct 1 1997;22(19):2265–2270; discussion 2271.

  43. Mulligan RP, Friedman JA, Mahabir RC. A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures. J Trauma. Mar 2009;68(3):587–592.

  44. Mulligan RP, Mahabir RC. The prevalence of cervical spine injury, head injury, or both with isolated and multiple craniomaxillofacial fractures. Plast Reconstr Surg. Nov 2010;126(5):1647–1651.

  45. Patel AA, Spiker WR, Daubs M, Brodke D, Cannon-Albright LA. Evidence for an inherited predisposition to lumbar disc disease. J Bone Joint Surg Am. Feb 2 2011;93(3):225–229.

  46. Patil PG, Turner DA, Pietrobon R. National trends in surgical procedures for degenerative cervical spine disease: 1990–2000. Neurosurgery. Oct 2005;57(4):753–758; discussion 753–758.

  47. Peterson L, Junge A, Chomiak J, Graf-Baumann T, Dvorak J. Incidence of football injuries and complaints in different age groups and skill-level groups. Am J Sports Med. 2000;28(5 Suppl):S51–57.

  48. Sebert SL, Brick JE, Anderson K. Acute low back pain findings and management in an academic medical center. W V Med J. Jul–Aug 1998;94(4):202–204.

APPENDIX C Inclusion and Exclusion lists consolidated

Body
part
ICD-9 # or
E-code
2009 ICD-9 Code Descriptions Cherkin &
Deyo ‘92
Inpt Hosp
for LBP
NHDS
HCUP
Back
HCUP
Sprains
&
Strains
Martin ‘08
Back and
neck
MEPS
data
Taylor ‘98
Inpt for
Back and
neck
Washingto
n and
Ontario
Einstadter
‘93 Inpt
Neck
Surgery
Washington
Angevine
‘03 Inpt
Neck
Surgery
NHDS
C 721.0 Cervical spondylosis without myelopathy EXCL INCL INCL INCL INCL INCL
C 721.1 Cervical spondylosis with myelopathy EXCL INCL INCL INCL INCL INCL
C 722.0 Displacement of cervical intervertebral disc without myelopathy INCL INCL INCL INCL INCL
C 722.4 Degeneration of cervical intervertebral disc INCL INCL INCL INCL INCL
C 722.71 Intervertebral disc disorder with myelopathy-cervical region INCL INCL INCL INCL INCL
C 722.81 Postlaminectomy syndrome-cervical region INCL INCL INCL INCL
C 722.91 Other and unspecified disc disorder-cervical region INCL INCL INCL INCL INCL
C 723.0 Spinal stenosis of cervical region INCL INCL INCL INCL INCL
C 723 Other disorders of the cervical region INCL
C 723.1 Cervicalgia INCL INCL INCL INCL
C 723.2 Cervico-cranial syndrome INCL INCL INCL INCL
C 723.3 Cervicobrachial syndrome (diffuse) INCL INCL INCL INCL INCL
C 723.4 Brachial neuritis or radiculitis INCL INCL INCL INCL
C 723.5 Torticollis, unspecified INCL INCL INCL INCL
C 723.6 Panniculitis specified as affecting neck INCL INCL INCL
C 723.7 Ossification of posterior longitudinal ligament in cervical region INCL INCL INCL INCL
C 723.8 Other syndromes affecting cervical region INCL INCL INCL INCL
C 723.9 Unspecified musculoskeletal disorders and symptoms referable to neck INCL INCL INCL INCL
C 738.2 Acquired deformity of the neck INCL INCL
C 739.1 Non allopathic lesions cervical INCL INCL
C 756.2 Congenital Anomalies of the Spine - cervical rib EXCL
C 784.0 Headache
C 805.0 Closed cervical vertebral fractures without mention of spinal cord injury INCL EXCL
C 805.1 Cervical fracture, open, without mention of spinal cord injury EXCL INCL EXCL
C 806.0 Cervical fracture, closed with spinal cord injury EXCL INCL EXCL
C 806.1 Cervical fracture, open with spinal cord injury EXCL INCL EXCL
C 839.0 Other, multiple, and ill-defined vertebral dislocations cervical vertebra, closed EXCL INCL EXCL
C 839.1 Other, multiple, and ill-defined vertebral dislocations cervical vertebra, open EXCL INCL EXCL
C 847.0 Sprains and strains of other and unspecified parts of back-neck INCL INCL INCL INCL
T 721.2 Thoracic spondylosis without myelopathy EXCL INCL INCL INCL
T 721.41 Thoracic spondylosis with myelopathy INCL INCL INCL
T 722.11 Displacement thoracic intervertebral disc without myelopathy INCL INCL INCL
T 722.31 Schmorl’s nodes-thoracic region INCL INCL INCL
T 722.72 Intervertebral disc disorder with myelopathy-thoracic region INCL INCL INCL
T 722.82 Postlaminectomy syndrome-thoracic region INCL INCL INCL
T 722.92 Other and unspecified disc disorder-thoracic region INCL INCL INCL
T 724.01 Spinal stenosis, other than cervical-thoracic region INCL INCL INCL
T 724.1 Pain in thoracic spine INCL INCL INCL
T 737.0 Adolescent postural kyphosis INCL
T 737.10 Kyphosis (acquired)(postural) INCL INCL INCL
T 737.1 Kyphosis acquired INCL
T 737.11 Kyphosis due to radiation INCL
T 737.34 Thoracogenic scoliosis INCL
T 737.41 Curvature of the spine associated with other conditions, kyphosis INCL
T 739.2 Non allopathic lesions, thoracic
T 805.2 Thoracic fracture, closed, without mention of spinal cord injury INCL EXCL
T 805.3 Thoracic fracture, open, without mention of spinal cord injury EXCL INCL EXCL
T 806.2 Thoracic fracture, closed with spinal cord injury EXCL INCL EXCL
T 806.3 Thoracic fracture, open with spinal cord injury EXCL INCL EXCL
T 847.1 Sprains and strains of other and unspecified parts of back-thoracic INCL INCL
TL 721.4 Thoracic or lumbar spondylosis with myelopathy INCL INCL
TL 722.1 Displacement of thoracic or lumbar inter-vertebral disc w/o myelopathy INCL INCL INCL
TL 722.5 Degeneration of thoracic or lumbar intervertebral disc INCL
TL 722.51 Degeneration of thoracic or thoracolumbar intervertebral disc INCL INCL INCL
TL 724.00 Spinal stenosis - unspecified region INCL INCL INCL INCL
TL 724.0 Spinal stenosis, other than cervical INCL
TL 724.09 Spinal stenosis, other than cervical-other INCL INCL INCL INCL
TL 724.4 Thoracic or lumosacral neuritis or radiculitis, unspecified INCL INCL INCL INCL
TL 724.5 Backache, unspecified INCL INCL INCL INCL
TL 839.2 Other, multiple, and ill-defined vertebral dislocations thoracic and lumbar vertebra, closed EXCL INCL EXCL
TL 839.3 Other, multiple, and ill-defined vertebral dislocations thoracic and lumbar vertebra, open EXCL INCL EXCL
L 721.42 Lumbar spondylosis w/o myelopathy INCL INCL INCL INCL
L 722.10 Displacement of lumbar inter-vertebral disc w/o myelopathy INCL INCL INCL INCL
L 722.32 Schmorl’s nodes lumbar region INCL INCL INCL INCL
L 722.73 Intervertebral disc disorder with myelopathy, lumbar region INCL INCL INCL INCL
L 722.83 Postlaminectomy syndrome lumbar region INCL INCL INCL INCL
L 722.93 Other and unspecified disc disorder, lumbar region INCL INCL INCL INCL
L 724.02 Spinal stenosis, other than cervical-lumbar region INCL INCL INCL INCL
L 724.2 Lumbago, low back pain, low back syndrome INCL INCL INCL INCL
L 724.3 Sciatica INCL INCL INCL INCL
L 737.2 Lordosis (acquired) INCL
L 737.2 Lordosis (acquired)(postural) INCL
L 737.21 Lordosis, postlaminectomy INCL
L 737.22 Other post surgical lordosis INCL
L 737.29 Lordosis acquired other INCL
L 737.42 Curvature of the spine associated with other conditions, Lordosis INCL
L 738.4 Acquired spondylolisthesis INCL INCL INCL
L 739.3 Nonallopathic lesions, lumbar region INCL INCL
L 805.4 Lumbar fracture, closed, without mention of spinal cord injury INCL INCL EXCL
L 805.5 Lumbar fracture, open, without mention of spinal cord injury EXCL INCL EXCL
L 806.4 Lumbar fracture, closed with spinal cord injury EXCL INCL EXCL
L 806.5 Lumbar fracture, open with spinal cord injury EXCL INCL EXCL
L 847.2 Sprains and strains of other and unspecified parts of back-lumbar INCL INCL INCL INCL
LS 721.3 Lumbosacral spondylosis w/o myelopathy INCL INCL INCL INCL
LS 722.52 Degeneration of lumbar or lumbosacral intervertebral disc INCL INCL INCL INCL
LS 724.8 Other symptoms referable to back INCL INCL INCL INCL
LS 724.9 Other unspecified back disorders INCL INCL INCL INCL
LS 756.11 Spondylolysis, lumbosacral region INCL INCL
LS 846.0 Sprains and strains - lumbosacral (joint) (ligament) INCL INCL INCL INCL
S 720.1 Spinal enthesopathy EXCL INCL INCL EXCL EXCL
S 720.2 Sacroilitis, not elsewhere classified EXCL INCL INCL EXCL EXCL
S 724.6 Disorders of sacrum INCL INCL INCL INCL
S 739.4 Nonallopathic lesions, sacral region INCL INCL
S 846 Sprains and strains of sacroiliac region INCL
S 846.1 Sprains and strains - Sacroiliac ligament INCL INCL INCL INCL
S 846.2 Sprains and strains - acrospinatus (ligament) INCL INCL INCL INCL
S 846.3 Sprains and strains - sacrotuberous (ligament) INCL INCL INCL INCL
S 846.8 Sprains and strains - other specified sites of sascroiliac region INCL INCL INCL INCL
S 846.9 Sprains and strains - unspecified site of sacroiliac region INCL INCL INCL INCL
S 847.3 Sprains and strains of other and unspecified parts of back-sacrum INCL INCL INCL INCL
SCX 805.6 Sacrum and coccyx fracture, closed, without mention of spinal cord injury INCL EXCL
SCX 805.7 Sacrum and coccyx fracture, open, without mention of spinal cord injury EXCL INCL EXCL
SCX 806.6 Sacrum and coccyx fracture, closed with spinal cord injury EXCL INCL EXCL
SCX 806.7 Sacrum and coccyx fracture, open with spinal cord injury EXCL INCL EXCL
CX 724.70 Unspecified disorder of coccyx INCL INCL
CX 724.7 Disorders of the coccyx INCL
CX 724.71 Hypermobility of coccyx INCL INCL
CX 724.79 Disorders of coccyx-other INCL INCL
CX 847.4 Sprains and strains of other and unspecified parts of back-coccyx INCL INCL
307.89 Psychogenic back pain INCL INCL
720 Ankylosing spondylitis and other inflammatory spondylopathies EXCL INCL EXCL EXCL
720.0 Ankylosing spondylitis EXCL INCL EXCL EXCL
720.8 Other inflammatory spondylopathies EXCL INCL EXCL EXCL
720.81 Other inflammatory spondylopathies in diseases classified elsewhere EXCL INCL INCL EXCL EXCL
720.89 Other inflammatory spondylopathies - other EXCL INCL INCL EXCL EXCL
720.9 Unspecified inflammatory spondylopathy EXCL INCL INCL EXCL EXCL
721 Spondylosis and allied disorders INCL
721.5 Spondylosis and allied disorders - Kissing Spine INCL INCL INCL INCL
721.6 Spondylosis and allied disorders - Ankylosing vertebral hyperostosis INCL INCL INCL INCL
721.7 Traumatic spondylopathy INCL INCL INCL INCL
721.8 Other allied disorders of the spine INCL INCL INCL INCL
721.90 Spondylosis of unspecified site without mention of myelopathy INCL INCL INCL INCL INCL
721.9 Spondylosis of unspecified site INCL
721.91 Spondylosis of unspecified site with myelopathy INCL INCL INCL INCL INCL
722 Intervertebral disc disorders INCL
722.2 Displacement of intervertebral disc, site unspecified, w/o myelopathy INCL INCL INCL INCL INCL
722.30 Schmorl’s nodes-unspecified region INCL INCL INCL INCL
722.3 Schmorl’s nodes INCL
722.39 Schmorl’s nodes-other INCL INCL INCL
722.6 Degeneration of intervertebral disc site unspecified INCL INCL INCL INCL INCL
722.70 Intervertebral disc disorder with myelopathy-unspecified region INCL INCL INCL INCL INCL
722.7 Intervertebral disc disorder with myelopathy INCL
722.80 Postlaminectomy syndrome-unspecified region INCL INCL INCL INCL
722.8 Postlaminectomy syndrome INCL INCL INCL
722.90 Other and unspecified disc disorder-unspecified region INCL INCL INCL INCL INCL
722.9 Other and unspecified disc disorder site unspecified INCL
724 Other and unspecified disorder of back INCL
737 Curvature of the spine - excludes congenital INCL
737.12 Kyphosis, postlaminectomy INCL
737.19 Kyphosis acquired-other INCL
737.30 Scoliosis [and kyphoscoliosis], idiopathic INCL INCL INCL
737.3 Kyphoscoliosis and scoliosis INCL
737.31 Resolving infantile idiopathic scoliosis INCL
737.32 Progressive infantile idiopathic scoliosis INCL
737.33 Scoliosis due to radiation INCL
737.39 Other kyphoscoliosis and scoliosis INCL
737.4 Curvature of the spine with other conditions INCL
737.40 Curvature of the spine associated with other conditions, unspecified INCL
737.43 Curvature of the spine associated with other conditions, Scoliosis INCL
737.8 Other curvatures of the spine INCL
737.9 Unspecified curvature of the spine INCL
738.5 Other acquired deformity of the back or spine INCL INCL
756.10 Anomaly of spine, unspecified INCL INCL
756.12 Spondylolisthesis INCL INCL
756.13 Congenital anomalies of the spine - absence of a vertebra INCL INCL
756.14 Congenital anomalies of the spine - hemivertebra INCL INCL
756.15 Congenital anomalies of the spine - congenital fusion of the vertebrae INCL INCL
756.16 Congenital anomalies of the spine - Klippel-feil INCL INCL
756.17 Congenital anomalies of the spine - spina bifida occulta INCL INCL
756.18 Congenital anomalies of the spine INCL INCL
756.19 Congenital anomalies of the spine - other INCL INCL
805 Fracture of vertebral column without mention of spinal cord injury INCL EXCL
805.8 Vertebral fractures, unspecified closed, without mention of spinal cord injury INCL INCL EXCL
805.9 Vertebral fractures, unspecified copen, without mention of spinal cord injury EXCL INCL EXCL
806 Fracture of vertebral column with spinal cord injury EXCL INCL EXCL
806.8 Vertebral fractures, unspecified closed with spinal cord injury EXCL INCL EXCL
806.9 Vertebral fractures, unspecified open with spinal cord injury EXCL INCL EXCL
839.4 Other, multiple, and ill-defined vertebral dislocations, closed - other EXCL INCL EXCL
839.5 Other, multiple, and ill-defined vertebral dislocations, open - other EXCL INCL EXCL
847 Sprains and strains of other and unspecified parts of back INCL
847.9 Sprains and strains of other and unspecified parts of back-unspecified INCL INCL INCL INCL INCL
996.4 Mechanical complication of internal orthopedic device, implant and graft INCL INCL
03.2 – 03.29 Chordotomy (procedure) EXCL
140–239.99 Neoplasms EXCL EXCL EXCL
630–676.9 Pregnancy EXCL EXCL EXCL
730.730.99 Osteomyelitis, periostitis, and other infections involving bone EXCL EXCL EXCL
E800–E849.9 Transportation Accidents EXCL EXCL

APPENDIX D Spine surgeries and procedures by year and code

ICD-9 Code Description 2002 2003 2004 2005 2006 2007 2008 2009
0302 Reopening of laminectomy site 67 60 104 78 114 122 138 110
0309 Other exploration and decompression of spinal canal 1748 2118 2194 2482 2772 2924 3039 3089
036 Lysis of adhesions of cord or nerve root 13 19 31 29 26 23 17 19
7770 Excision of bone for graft 8 10 20 10 5 10 59 107
7779 Excision of bone for graft 361 364 341 303 266 352 858 946
7869 Removal of internal fixation device (non-specific - vertebral, pelvic or phalangeal) 89 117 154 136 156 178 227 256
8050 Excision or destruction of intervertebral disc, unspecified 6 5 9 5 4 6 11 21
8051 Excision of intervertebral disc 2375 2583 2664 2808 2771 2990 3407 3381
8052 Intervertebral chemonucleolysis 2 2 1 1 4 1
8059 Other destruction of intervertebral disc 2 7 5 4 5 4 5 8
8100 Spinal fusion, not otherwise specified 21 25 33 15 24 21 24 20
8101 Atlas-axis spinal fusion 21 40 53 33 28 45 40 46
8102 Other cervical fusion, anterior technique 957 1098 1207 1254 1391 1449 1634 1691
8103 Other cervical fusion, posterior technique 190 243 272 306 358 407 485 478
8104 Dorsal and dorsolumbar fusion, anterior technique 29 31 27 27 38 26 36 29
8105 Dorsal and dorsolumbar fusion, posterior technique 56 58 79 87 134 116 143 134
8106 Lumbar and lumbosacral fusion, anterior technique 88 73 95 88 121 106 150 175
8107 Lumbar and lumbosacral fusion, lateral transverse process technique 56 80 61 60 60 86 96 135
8108 Lumbar and lumbosacral fusion, posterior technique 411 461 522 638 658 794 1145 1180
8109 Other spinal fusion 1
8130 Refusion of spine, not otherwise specified 1 1 1 2
8131 Refusion of atlas-axis spine 3 1 1 4 3
8132 Refusion of other cervical spine, anterior technique 19 26 20 34 28 32 42 40
8133 Refusion of other cervical spine, posterior technique 6 7 18 14 19 33 32 38
8134 Refusion of dorsal and dorsolumbar spine, anterior technique 4 5 2 3 7
8135 Refusion of dorsal and dorsolumbar spine, posterior technique 4 6 3 7 8 14 17
8136 Refusion of lumbar and lumbosacral spine, anterior technique 3 1 5 12 2 7 11 12
8137 Refusion of lumbar and lumbosacral spine, lateral transverse process technique 5 1 3 2 5 8 5
8138 Refusion of lumbar and lumbosacral spine, posterior technique 22 17 29 35 41 53 57 95
8139 Refusion of spine, not elsewhere classified 2 1 1 2
ICD-9 Uniques = 42926 4430 4986 5236 5559 5857 6220 6971 7210

APPENDIX D Surgeries and Procedures by year and code

CPT Code Description 2002 2003 2004 2005 2006 2007 2008 2009
22100 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical 2 1 12 3 1 2 2
22101 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic 1 2 1
22102 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar 6 3 4 4 4
22103 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment 1 13 5 4 1
22110 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical 3 3 4 1 3 3
22112 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic 2 4 1
22114 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar 2 1 2 2
22116 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment 1 1 5 5 2
22206 Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); thoracic 2 2
22207 Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); lumbar 1 4
22208 Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment 2 3
22210 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; cervical 4 4 3 1 2 3
22212 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; thoracic 2 4 1 3 3 6 3
22214 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; lumbar 3 3 2 4 5 5 9 17
22216 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; each additional vertebral segment (List separately in addition to primary procedure) 1 2 2 4 8 9 11
22220 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical 2 3 1 1 5 9 5 8
22222 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic 1 2 1
22224 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar 6 5 5 2 3 4 4
22226 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment 1 2 1 1 2 2 4
22305 Closed treatment of vertebral process fracture(s) 6 5 4 4 2 5 5 5
22310 Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing 8 8 17 19 17 21 30 22
22315 Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing, with or without anesthesia, by manipulation or traction 72 53 5 5 5 10 6 2
22318 Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting 3 4 1 2 7 9 6 7
22326 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; cervical 5 6 3 15 10 11 14 14
22327 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; thoracic 7 11 5 10 13 13 17 13
22328 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment 1 8 6 10 10 6 7 10
22505 Manipulation of spine requiring anesthesia, any region 3 2 3 8 6 9 7 21
22520 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic 17 35 29 48 70 80 95 67
22521 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar 33 39 28 53 66 117 124 133
22523 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic 16 45 88 95
22524 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); lumbar 25 80 109 133
22525 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); each additional thoracic or lumbar vertebral body 7 24 40 42
22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level 3 39 31
22527 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels 5 14 15
22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) 3 4 2 6 8 5 6 4
22595 Arthrodesis, posterior technique, atlas-axis (C1–C2) 3 5 3 14 9 11 6 15
22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment 27 52 52 85 120 175 282 277
22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique) 15 27 36 31 55 52 74 57
22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) 60 81 178 202 240 365 641 752
22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment 86 168 240 301 394 558 995 1076
22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar 22 57 100 125 149 212 440 479
22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments 2 4 6 12 12 10
22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments 4 6 2 1 3 2 10 11
22804 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments 3 1
22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments 2 1 2 1
22819 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments 1 1
22830 Exploration of spinal fusion 4 6 16 25 26 35 76 69
22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) 41 52 69 115 144 164 378 409
22841 Internal spinal fixation by wiring of spinous processes 2 3 4 4 5 5 6 16
22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments 73 121 204 229 319 424 664 708
22843 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments 9 12 12 24 31 23 55 48
22844 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments 2 5 1 1
22845 Anterior instrumentation; 2 to 3 vertebral segments 134 232 243 264 330 422 688 684
22846 Anterior instrumentation; 4 to 7 vertebral segments 15 30 34 42 74 83 112 93
22847 Anterior instrumentation; 8 or more vertebral segments 1 1 1 4 3
22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum 3 3 3 11 18
22849 Reinsertion of spinal fixation device 5 4 13 10 19 29 36
22850 Removal of posterior nonsegmental instrumentation (eg, Harrington rod) 3 3 5 5 9 11 27 22
22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace 95 143 219 285 376 441 922 1081
22852 Removal of posterior segmental instrumentation 22 12 20 29 18 37 51 52
22855 Removal of anterior instrumentation 6 7 12 18 13 28 40 29
22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical 28
22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar 2 12 14
22862 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical 1
22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar 1 1
CPT Uniques = 7890 383 500 559 617 890 1200 1910 2084

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