Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
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.
Level(s) of the spinal column and number being fused:
As you can see in the picture below, the human vertebral column consists of 33 vertebrae divided into five regions:
- Sacrum—5 (sometimes 6)
When reviewing the operative note, look for what level(s) are being fused together. A level involves two vertebrae and the space between them (interspace) containing the disc. In ICD-10-PCS, two adjacent vertebrae separated by an interspace (level) is call a vertebral joint.
How to report multiple levels?
When the surgeon documents that a fusion consisted of only two vertebrae and they are of the same level (such as lumbar) then this is counted as only one level. However, in the same procedure if the surgeon also performs a fusion of another level (such as sacrum), this part of the fusion would also need to be reported.
- If a patient presents and undergoes a lumbar fusion to include L3-L5, this would be counted as two vertebral joints (L3 to L4 and L4 to L5). Each of these two vertebral joints will be made immobile by the fusion. One way to think of this is like “welding” the two together. Sometimes, we see coders count each level and report as four vertebral joints being fused. But remember in ICD-10-PCS, two adjacent vertebrae separated by an interspace is a vertebral joint.
- If a patient presents and undergoes a spinal fusion of L4-S1, this would be counted as two vertebral joints (L4 to L5 and L5 to S1), and reported with two ICD-10-PCS codes to include both the lumbar and sacral region of the vertebra. This is because the fusion includes two regions within the vertebrae (lumbar and lumbosacral). As above, this is only two vertebral joints being fused together but of two different regions (lumbar and lumbosacral).
- If a patient presents and undergoes a spinal fusion of C5-T2, this would be counted as four vertebral joints (C5 to C6, C6 to C7, C7 to T1 and T1-T2), but reported with ICD-10-PCS codes to include both the cervical, cervicothoracic and the thoracic region of the vertebra.
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2019
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.
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).
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).
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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