Part 11: Spinal Fusion Coding — Computer Assisted Navigation

by Oct 2, 2019Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding0 comments

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.

Computer assisted navigation is often used during spinal fusion surgery. This tool will enhance the accuracy of screw placement in posterior fusions. By using this type of tool, not only does it help with placement accuracy, it reduces the patient and the staff’s exposure to radiation and reduces procedure time. Using computer assisted navigation also allows for real-time images.

In the operative note, look for terms such as “O-arm” and “Stealth navigation.” These are the two that we see most often. Oftentimes, the surgeons will only state the name of the device in the operative note. When coders are not sure what a specific device is within an operative note, research should be done to determine if this is a computer assisted navigation device.

How is computer assisted navigation coded?

When computer assisted navigation is used during a spinal surgery/fusion, ICD-10-PCS code 8E0WXBZ (computer assisted procedure of trunk region) is most commonly reported for spinal surgery. However, there are other qualifiers of “with Fluoroscopy,” “with Computerized Tomography,” and “with Magnetic Resonance Imaging” to select from if the documentation is present.

View parts 1-10 of this series here: hiacode.com/topics/series/spinal-fusion-coding/.

Be on the lookout for Part 12 which will discuss intra-operative monitoring.


Happy Coding!

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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