Part 8: Spinal Fusion Coding — Discectomy During Spinal Fusion
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
In Part 7, we focused on identifying any instrumentation that may be used during a spinal fusion. In Part 8, we are going to focus on identifying if a discectomy is performed and if this is an excision or a resection of the disc.
What is a discectomy?
A discectomy is surgical removal of any herniated or damaged disc in the patient’s spine. When a disc is herniated (slipped, ruptured, bulging or prolapsed disc), the spinal nerves may become irritated and “pinched.” The discectomy does not provide relief with the actual back/neck pain, but does typically relieve the associated radiating pain (radiculopathy) from the pressure/irritation on the spinal nerve.
Determining if a discectomy an excision or a resection?
A discectomy can be either an excision (partial/removal of part of the disc) or a resection (total/removal of the entire disc). The operative report should describe if part or all of the disc material is removed. Most often, just the fragment of the disc that is irritating the nerve is removed leaving the remaining disc intact. If the entire disc is removed, the disc space may need to be filled with synthetic bone substitute or from the patient’s own bone (see Parts 5&6 of this series). Discectomy is almost always performed during spinal fusion surgery.
Terms to look for:
- Excision of disc material (partial)—removal of free disc fragments, removed the displaced disc, excised the disc, or partial discectomy
- Resection of disc (total)—total, complete, thorough or radical removal of the disc
When discectomy is performed (partial or total) during spinal fusion surgery the discectomy is reported separately. When discectomy is performed on multiple levels (cervical, thoracic, lumbar, sacral, cervicothoracic, thoracolumbar or lumbosacral) each intervertebral disc would be coded, but only once per level (i.e., cervical, thoracic, lumbar, etc.) An example would be a patient that has L3-S1 partial discectomies. This would be reported with two ICD-10-PCS codes. One for the lumbar discectomy (excision at L3 and L5 interspaces) and one for the lumbosacral discectomy (excision L5-S1 interspace). Even though two lumbar vertebral discs (L3-L4 and L4-L5) were excised this is only reported once. This is because the vertebral level designations of lumbar spinal cord do not constitute separate and distinct body parts anatomically according to AHA, and therefore, the multiple procedures guideline B3.2b does not apply.
View parts 1-7 of this series here: hiacode.com/topics/series/spinal-fusion-coding/.
Be on the lookout for Part 9 which will discuss how to identify if a decompression of the spinal nerve or spinal cord was also completed during the spinal fusion.
Coding Clinic, Second Quarter 2016: Page 6-7, 16
Coding Clinic, Second Quarter 1990: Page 27
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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In Parts 1, 2 and 3 we learned about what sepsis is, sequencing of sepsis and what documentation is needed to report severe sepsis. In Part 4, we will look at clinical indicators needed to clinically support the diagnosis of sepsis and determine if a query is indicated.
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In the previous three parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2020 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2020.
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2020. On August 2, 2019, CMS published the Final Rule for IPPS (CMS-1716) FY2020 IPPS Final Rule.
In Part 1 of this 4 part series we discussed some of the new ICD-10-CM diagnosis changes. In Part 2 we present the significant ICD-10-PCS procedure code changes. There are 72,184 total ICD-10-CM codes for FY2020.
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We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
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In Part 8, we focused on identifying if a discectomy was performed, and if so, if it was a partial or a total discectomy. In Part 9, we are going to focus on identifying if a decompression was performed, and if so, was it of the spinal cord, spinal nerves or both?
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Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
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