ࡱ> GIF bjbj:: 4(PPrrrrr,<t<<<<<<<,>@1<r1<YrrF<YYYrrr<Y<YY9;@f6}&F/:";\<0<Q:BxAYxAD;Yr;\1<1<Y<xA 8:    MASTER DIAGNOSIS SHEET MEDICARE Patients Name: _______________________________________________________ Date: __________________ PRIMARY ICD-9 Dx Codes Names of Vertebra 739.0 Occipitocervical (Occ-C1) 739.1 Cervical (C1-C7) 739.1 C1 (Atlas) 739.1 C2 (Axis) 739.2 Dorsal (D1-D12) or 739.2 Thoracic (T1-T12) 739.3 Lumbar (L1-L5) 739.4 Sacrococcygeal (S) Pelvis SECONDARY ICD-9 Diagnosis Category III- ICD-9 (diagnoses that may require longer term treatment): 721.7 Traumatic spondylopathy 722.0 Displacement of cervical intervertebral disc without myleopathy 722.10 Displacement of lumbar intervertebral disc without myleopathy 722.11 Displacement of thoracic intervertebral disc without myelopathy 722.4 Degeneration of cervical intervertebral disc 722.51 Degeneration of thoracic or thoracolumbar intervertebral disc Degeneration of lumbar or lumbrosacral intervertebral disc 722.6 Degeneration of invertebral disc, unspecified site 722.81 Post laminectomy syndrome, cervical region 733.82 Post laminectomy syndrome, thoracic region 722.83 Post laminectomy syndrome, lumbar region 724.3 Sciatica Current Diagnosis: _______________ 5. _______________ _______________ 6. _______________ _______________ 7. _______________ DC Signature __________________________________ _______________ 8. _______________ Date: _______________________________ Update Diagnosis _______________ 5. _______________ _______________ 6. _______________ _______________ 7. _______________ DC Signature __________________________________ _______________ 8. _______________ Date: _______________________________ Category II- ICD-9 Diagnosis (diagnoses that generally require moderate term treatment): 353.0 Brachial plexus lesions 353.1 Lumbrosacral plexus lesions 353.2 Cervical root lesions, NEC 353.3 Thoracic root lesions, NEC 353.4 Lumbrosacral root lesions, NEC 353.8 Other nerve root and plexus disorders 719.48 Pain in joint (other specified sites) (must specify spine) 720.1 Spinal enthesopathy 722.91 Other and unspecified disc disorder, cervical region 722.92 Other and unspecified disc disorder, thoracic region 722.93 Other and unspecified disc disorder, Lumbar region 723.0 Spinal stenosis in cervical region 723.2 Cervicocranial syndrome 723.3 Cervicobrachial syndrome 723.4 Brachial neuritis or radiculitis 723.5 Torticollis, unspecified 724.01 Spinal stenosis, thoracic region 724.02 Spinal stenosis, lumbar region 724.4 Thoracic or lumbrosacral neuritis or radiculitis 724.6 Disorders of sacrum, ankylosis 724.79 Disorders of coccyx, coccygodynia 724.8 Other symptoms referable to back, facet syndrome 729.1 Myalgia and myositis, unspecified 729.4 Fasciitis, unspecified 738.40 Acquired spondylolisthesis 756.12 Spondylolisthesis 846.0 Sprains & strains of sacroiliac region, lumbosacral (joint;ligament) 846.1 Sprains & strains of sacroiliac region, sacroiliac ligament 846.2 Sprains & strains of sacroiliac region, sacrospinatus (ligament) 846.3 Sprains & strains of sacroiliac region, sacrotuberous (ligament) 846.8 Sprains & strains of sacroiliac region, other specified sites of sacroiliac region 847.0 Sprains & Strains of other and unspecified parts of back, neck 847.1 Sprains & Strains of other and unspecified parts of back, thoracic 847.2 Sprains & Strains of other and unspecified parts of back, lumbar 847.3 Sprains & Strains of other and unspecified parts of back, sacrum 847.4 Sprains & Strains of other and unspecified parts of back, coccyx Category I-ICD-9 Diagnosis (diagnoses that generally require short term treatment): Tension headache Contracture joint (fixation, spine only) 721.0 Cervical spondylosis without myelopathy 721.2 Thoracic spondylosis without myelopathy Lumbosacral spondylosis without myelopathy 721.6 Ankylosing vertebral hyperostosis 721.90 Spondylosis of unspecified site without myelopathy 721.91 Spondylosis of unspecified site with myelopathy 723.1 Cervicalgia 724.1 Pain in thoracic spine 724.2 Lumbago 724.5 Backache, unspecified 784.0 Headache #$%[blu    & ' : I J |vv|v|vmhBhBCJ hK^CJ h` CJ hhoCJh` h` CJ h` 5CJh` h` 5CJ hr5CJ h+h+hhohr5CJhhohrCJhgIhG$ CJ hOCJhgIhG$ 5CJ hG$ 5hhoh` hrhG$ hhohG$ CJ hrCJ)#$%  ; 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