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.
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.
Severe sepsis occurs when sepsis progresses and signs of organ dysfunction/failure develop. One site stated that approximately 30% of patients with severe sepsis do not survive. Patients may develop one organ dysfunction/failure, multi-system organ failure and/or septic shock.
In Part 2 of our Sepsis Series, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
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.
This is Part 1 of a 4 part series on the FY2020 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. There are 72,184 total ICD-10-CM codes for FY2020.
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).
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.”
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
We interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them. This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?