As the largest outsource coding provider in the country we have identified trends and gained unique insights from our coders throughout the transition to ICD-10. We are sharing these insights with the broader HIM Community through our bi-weekly blog series "ICD-10 Quick Tips."
The subject matter for this series is currated based on the trending topics in our online question and answer system which services over 1,200 of our HIM professionals. Our Subject Matter Experts have an average of 20 years of experience and are considered leaders in their field.
This week's post comes from National Compliance and Quality Audit Manager, Melissa McLeod, CDIP, CCDS, CCS, CPC, CPC-1, andAHIMA Approved ICD-10 Trainer.
Did I hear you all groan? Loudly? Spinal fusions are one of the most difficult challenges for coders of all specialties to tackle…IP and OP alike. I would like to clear up some of the confusion relating to this coding topic. I know you have all probably had some education on this area and it is still as clear as mud right? Let’s see if I can help with that.
Correct code assignment for spinal surgery procedures is best achieved with the development of an understanding of related anatomy, surgical terminology, and procedure descriptions…so here goes!
A very important coding note for the coder to understand is the body part values for fusion procedures are classified as joints—not as individual vertebrae themselves. The vertebral joint identified therefore involves two vertebrae—the upper and the lower; however, the body part value in PCS is considered a single joint.
- The body part value assigned is the specific joint being fused
- If the fusion was performed at L1-L2, then the body part value assigned is “0-Lumbar vertebral joint” meaning one joint
- If the fusion was performed at L1-L3, then the body part value assigned is “1-Lumbar vertebral joint, 2 or more,” meaning two joints
Coders need to look to see how the patient is positioned. If the patient is positioned face down, the physician is using a posterior approach. In the majority of cases, it means the physician will be working on the posterior column. Be mindful the approach is not going to tell you exactly which column the physician is operating on…Be very careful when you read the operative report.
In a spinal fusion, a solid bridge is formed between two vertebral segments in the spine to stop the movement in that particular section of the spine. Bone graft and/or bone graft substitute is needed to create the environment for the solid bridge to form. The bone graft does not form a fusion at the time of the surgery. Instead, the bone graft provides the foundation and environment to allow the body to grow new bone and fuse a section of the spine together (into one long bone).
Spinal fusions may use a variety of different devices such as autologous tissue substitute, interbody fusion device, internal fixation device, non-autologous tissue substitute, and external fixation device. Guideline B3.10c delineates how to apply the device value for fusion procedures when a combination of devices is used. At the time of the fusion surgery, instrumentation (e.g. screws and rods) is typically used to provide stability for that particular section of the spine for the first few months after surgery; over the long term, a solid fusion of bone healing together provides stability.
Some fusion procedures involve the insertion of a spinal stabilization device performed in conjunction with the placement of an interbody fusion device. Dynamic Stabilization System and other stabilization systems are not synonymous with internal fixation devices used in the process of fusion and are coded separately. Rods, plates and screws used in the performance of spinal fusion are not coded separately. Spinal stabilization devices provide a different service and support the spine without facilitating fusion.
When bone marrow is harvested for a spinal fusion from a different anatomical site, the procedure is coded separately.
- Root operation: extraction
When bone is harvested for a spinal fusion from a different anatomical site, the procedure is coded separately.
- Root operation: excision
There has been much discussion surrounding the coding of discectomy procedures during spinal fusion. Latest CC (2nd Qtr. 2014) direction indicates to code discectomy (or resection) during spinal fusion procedures. Excision or resection is dependent on the amount of disc removed. Well, there you have it, spinal fusion 101…did I help?