Part 1: Spinal Fusion Coding — Diagnoses Responsible
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
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. The spine has many demands as it holds up your head, shoulders and upper body. It allows you to stand up straight and provides flexibility to allow bending and twisting. The vertebrae (small bones in spine) also protect the spinal cord as they are connected together. The vertebrae are stacked on top of each other and create the natural curvature of the back
Most Common Diagnoses Associated With The Need For Spinal Fusion:
- Degenerative disc disease (DDD) (disc degeneration)—often causes weakness, numbness and pain. DDD is age-related and is when one or more of the discs between the vertebrae of the spinal column breaks down or deteriorates. DDD is not a true disease but develops with aging. When degeneration/DDD occurs, the rubbery, elastic material that provides padding (the discs) between the vertebrae become worn, crack, dry out and no longer offer the protection needed.
- Spinal stenosis—narrowing of the spinal and nerve root canals. Spinal stenosis occurs most often in the lumbar and cervical spine. The narrowing causes pressure on the nerves throughout the spine. Most spinal stenosis diagnoses occur due to something happening to narrow the spine, but can be due to being born with a small spinal canal (not common). Common causes are from osteoarthritis/spondylosis, bone spurs, herniated disks, thickened ligaments that bulge, tumors and spinal injuries.
- Spondylolisthesis—this is a condition when one of the vertebrae slip out of normal position and onto the vertebra below it. This slippage may cause the bone to press on a nerve. There are many types of spondylolisthesis, but the most common are congenital (present at birth), isthmic (results from spondylosis) and degenerative (most common form due to aging after 40).
- Herniated disk/slipped disk/ruptured disk—occurs when the gel-like center of a disc ruptures through a weak area in the tough outer wall, similar to the filling being squeezed out of a jelly doughnut. When the disk is herniated it can irritate nerves that result in pain, numbness or weakness of the arm/leg. Some people that have herniated disks experience no pain and is oftentimes an incidental finding during radiology testing.
- Scoliosis—a side-to-side curvature of the spine. In adults this is most commonly due to deterioration of facet joints that cause the spine bones to tilt and shift to one side.
- Lordosis—the spine curves inward at the lower back and is also called swayback. Most commonly this is due to kyphosis, obesity, osteoporosis and spondylolisthesis.
- Kyphosis—the spine curves forward and shifts the center of balance in front of the hip and is most commonly due to osteoporotic compression fractures and the patient is unable to stand up straight.
- Pseudoarthrosis—this is referred to as non-union and means ‘false joint’. This is the result of a failed spinal fusion.
- Radiculopathy—referred to as pinched nerve in the spine
- Myelopathy—is a very serious condition and can cause permanent spinal cord injury. Myelopathy is caused from severe pressure on the spinal cord from spinal stenosis, spinal trauma, spinal infections, autoimmune disease, tumors and neurological and congenital disorders. “Myelo” means spinal cord or bone marrow and in the case of “myelopathy” affects the spinal cord.
- Neurogenic claudication—common symptom of lumbar spinal stenosis. The stenosis is causing impingement or inflammation of the nerves emanating from the spinal cord.
These are just the most common causes of spinal surgery/fusions. If coders don’t know what the diagnoses are it will be very difficult to know what to report for both ICD-10-CM and ICD-10-PCS. There are multiple Coding Clinics available with guidance for both diagnoses and procedure reporting.
The next 13 parts will focus on the spinal fusion and the associated procedures. Be on the lookout for Part 2, that will discuss if the fusion is an initial fusion or refusion.
Below are several references, however there are many more that are not listed here that will provide assistance in reporting ICD-10-CM codes for diagnoses, that result in the need for spinal fusions.
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2018: Page 18 &19
Coding Clinic for ICD-10-PCS, First Quarter 2016: Page 17
Coding Clinic for ICD-10-CM/PCS, First Quarter 2019: Page 19
Coding Clinic for ICD-10-CM/PCS, Second Quarter 2018: Page 14 & 15
Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Page 18
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2017: Page 24
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.
This is Part 5 of a five part series on the new 2021 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
This is Part 4 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes in the urinary, nervous, ocular and auditory systems. There are 2 new urinary/male reproductive system codes with no revisions or deletions; 3 new female reproductive codes with 2 deletions, 0 new with 4 deleted nervous system codes with 5 revisions; 5 new eye category III codes; and finally a 2 new auditory codes with one deletion.
This is Part 3 of a five part series on the new 2021 CPT codes. In this series we will explore the cardiovascular system CPT changes. There are 5 new cardiovascular CPT codes added with 0 deletions and 4 revisions.
This is Part 2 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include some examples to help the coder understand the new codes. There are 0 new musculoskeletal CPT codes added with 0 deletions and 2 major revisions along with an extensive update to arthroscopic loose body removal requirements. For the respiratory system, there were 2 new codes, one code deletion and no revisions.
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
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 FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
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 FY2021.
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.