Part 5: Spinal Fusion Coding — Identifying the Approach Being Used for Fusion
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both). When coding a spinal fusion record, the operative report should be reviewed to determine if the fusion is being performed via anterior approach, posterior approach or even both. Let’s look at what this means.
How is the patient positioned on the table for surgery?
When reading the operative note, the coder will see documentation of how the patient is placed on the operative table. Ask yourself “how is the surgeon getting to the spine?”
- Anterior approach—supine (face up). This means that the surgeon is going through the front of the neck for a cervical fusion, through the abdominal region for a lumbar/lumbosacral fusion, and through the sternum/sternocleidomastoid for the thoracic portion of the spine. There are many benefits of using the anterior approach. This allows the surgeon to have excellent visualization and access to the spine. With advanced technology, the incision site can be as small as 3 inches.
- Posterior approach—prone (face down/lateral decubitus with the affected side upwards). This means that the surgeon is going through the back to perform the spinal fusion (cervical, thoracic, lumbar and lumbosacral). This is the most direct access to the view the spine.
- Combined approach—the surgeon may determine that both the anterior and the posterior approach are necessary to complete the spinal fusion. In this case, the documentation would describe that the patient was turned and placed in a different position.
Coding tip: It is not the approach alone of the spinal fusion that will impact the DRG, but the spinal columns that are being fused. If one column is fused (anterior OR posterior) through both an anteriorAND posterior approach, this will not group to the combined spinal fusion DRG’s 453-455. For example, if the anterior column is fused by both an anterior approach and posterior approach and coded as such, DRG’s 456-460 will be assigned. However, if the different spinal columns (anterior AND posterior) are being fused by the same approach (posterior), then the combined spinal fusion DRG’s 453-455 would be assigned with a larger relative weight to reflect two different columns being fused via the same approach (posterior).
View parts 1-4 of this series here: hiacode.com/topics/series/spinal-fusion-coding/.
Be on the lookout for Part 6 which will discuss how to identify the type of bone graft being used for the spinal fusion.
Coding Clinic, First Quarter 2013: Page 25-29
Coding Clinic, Second Quarter 2014: Page 6-7
Coding Clinic, Third Quarter 2014: Page 36
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.
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.
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.
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
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?
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.
In Part 6, we focused on identifying the type of bone graft product used for the spinal fusion. In Part 7, we are going to focus on identifying any instrumentation or device used.
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
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.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
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Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
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