Part 14: Spinal Fusion Coding — Spinal Fusion Series Summary
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
We have finished with the step-by-step coding tidbits on coding of spinal fusions.
Spinal Fusion Series Summary
Most common diagnosis associated with the need for spinal fusion:
- Degenerative disc disease/degeneration
- Spinal stenosis/neurogenic claudication
- Herniated disc/slipped disc/ruptured disc
- Radiculopathy/pinched spinal nerve
- Pseudoarthrosis (requiring re-fusion)
- Injury resulting in damage to the initial fusion
- Complications of the initial area fused
In ICD-10-PCS, initial and refusions are coded to the same root operation “fusion”
Determining the level(s) fused and number of vertebrae:
- There are five regions of the spine: cervical (7), thoracic (12), lumbar (5), sacrum (5 or 6) and coccyx (4)
- Two adjacent vertebrae separated by an interspace is called a vertebral joint
- When multiple vertebral joints are involved in the spinal fusion, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier
Identifying the spinal column being fused:
- Anterior column (refers to the spine that is at the front of the body)
- Posterior column (refers to the spine that is at the back of the body)
- Both columns fused? Be sure and report ICD-10-PCS codes for both the anterior and posterior column spinal fusion
- Anterior and posterior columns may be fused via one incision without the need to turn the patient
What approach is being used for the spinal fusion?
- Is the surgeon going through the front of the body/abdominal area/flank or front of the neck?
- For anterior approach the patient will be in the supine position (face up) and the incision will be in the abdomen (or side), sternocleidomastoid, front of the neck (or side)
- For posterior approach the patient will be in the prone position (face down) and the incision will be in the back
- Combined approaches are sometimes used. When this occurs the operative note should describe turning the patient over. The patient will have an incision in the front (anterior) and in the back (posterior)
Types of bone graft used:
- Autograft—comes from the patient’s own bone
- Allograft—this is bone that comes from a cadaver or bone graft substitute/tissue bank
- A combination of autograft and allograft/bone graft substitute are often used at the same site to render the site immobile. There is a hierarchy to follow when combinations of devices are sued on the same vertebral joint. You can find this in the OCG for PCS 2019 Page, 7
Was instrumentation or devices used?
- While reading the operative note, look for terms such as rods, plates, screws, cages, hooks or cable to see if any instrumentation was used to stabilize the spine
- For the root operation of “fusion” to be coded during spinal fusion with instrumentation or devices used, bone graft or bone graft substitute must also be used. Insertion of instrumentation and/or devices alone does not constitute a spinal fusion
Was discectomy performed during spinal fusion?
- A discectomy is surgical removal of any herniated or damaged disc in yours spine
- Look for diagnoses such as radiculopathy, leg pain, arm pain, or myelopathy to name a few
- Discectomy is coded in ICD-10-PCS as an excision or a resection. Excisional discectomy is partial removal of the disc (removal of free fragments, removed the displaced disc, excised the disc or partial discectomy). Resection discectomy is total removal of the disc (total, complete, thorough or radical removal of the disc)
- Discectomy performed during spinal fusion is separately reportable
Was decompression done during spinal fusion?
- Look for terms such as release, laminectomy, or decompression in the operative note
- Determine if the spinal nerve root was released or the spinal cord
- If both, spinal nerves and spinal cord are released, both should be coded (only report once per spinal column level/region)
- Diagnoses that typically require decompression to be performed at the time of spinal fusion are spinal stenosis, claudication, radiculopathy and myelopathy
Can coders report the removal of hardware from a previous spinal fusion or is it included in the new fusion/refusion ICD-10-PCS code?
- YES! Removal of hardware from a previous spinal fusion should be coded in addition to the spinal fusion. The removal of the hardware has a separate objective than the fusion
- ICD-10-PCS codes would be assigned for each spinal column level/region that hardware is removed from. The new spinal fusion will include any new hardware that is used
Computer assisted navigation:
- Used very often during spinal fusion to enhance the accuracy of screw placement in posterior fusions and reduces the patient and staff’s exposure to radiation and reduces procedure time
- Look for terms in the operative note such as “O-arm” and “Stealth navigation” as these are the two most common used
Intra-operative peripheral neuro monitoring:
- This is used to reduce the number of postoperative neurological complications and replaces the neurological examination while the patient is under anesthesia
- Look for EMG, SSEP, and MEP in the operative note
Is harvesting of the autograft for spinal fusion coded separately or included in the spinal fusion code?
- YES—if the bone is removed at a different body site than the spinal fusion
- NO—if the bone is removed at the site of the spinal fusion
ICD-10-PCS Official Guidelines for Coding and Reporting 2019
Coding Clinic, Second Quarter 2014: Page 6-7
Coding Clinic, Third Quarter 2013: Page 25
Coding Clinic for ICD-10-CM/PCS, First Quarter 2018: Page 8 & 22
Coding Clinic for ICD-10-CM/PCS, First Quarter 2017: Page 21
Coding Clinic for ICD-10-CM/PCS, Second Quarter 2017: Page 23
Coding Clinic, Third Quarter 2014: Page 30 & 36
Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Page 70
Coding Clinic, Second Quarter 2015: Page 14
Coding Clinic, First Quarter 2015: Page 26
Coding Clinic, Second Quarter 2016: Page 6-7, 16
Coding Clinic, Second Quarter 1990: Page 27
Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Pages 18 & 70
Coding Clinic for ICD-10-CM/PCS, First Quarter 2019: Pages 19, 28-30
Coding Clinic for ICD-10-CM/PCS, Second Quarter 2018: Pages 14-15, 22
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2018: Pages 18 & 19, 30
Coding Clinic, First Quarter 2013: Pages 21, 25-29
Coding Clinic for ICD-10-CM/PCS, First Quarter 2016: Page 17
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 June CMS released the final ICD-10-PCS codes for FY2022, which begins October 1, 2021. We are giving you a sneak peek at the changes. HIA will have a full educational module on these changes available later this summer.
CMS released the IPPS proposed rule on 4/27/21 outlining the proposed changes to the Inpatient Prospective Payment System for FY2022, which begins October 1, 2021. Later this year, sometime in August, CMS will release the Final Rule. Currently CMS is reviewing responses to their proposed rule and will address them in the final rule.
A medical coding audit is a process that includes internal or external reviews of medical coding and billing accuracy, procedures or policies in place, and any other component that affects the medical record documentation. Medical coding audits…
Anticoagulants and antiplatelets are used for the prevention and treatment of blood clots that occur in blood vessels. Oftentimes, anticoagulants and antiplatelets are referred to as “blood thinners,” but they don’t actually thin the blood at all. These drugs slow down the body’s process of making clots. Their main function is to keep the patient’s blood from clotting or turning into solid clumps of cells. These drugs do this by interfering with either fibrin or platelets in the blood.
Carotid artery disease is a vague category that can incorporate many different carotid artery issues. Some physicians may feel that they are being clear the patient has plaque, stenosis, or occlusion of the artery, but in ICD-10-CM the specificity must be included in the documentation.
10 ICD-10 Codes for Superheroes. Superman: T78.2XXA Anaphylactic reaction; substance: kryptonite. Batman: F44.81 Dissociative identity disorder. Robin: F60.7 dependent personality. The Hulk: L30.4 Erythema intertrigo. Wonder Woman: T24.032A Burn of unspecified degree of left lower leg. Black Panther S93.401A Sprain…
Practices have not seen many revisions to the Evaluation and Management (E/M) office / outpatient visit guidelines in three decades – until now. As of January 1, there are new E/M coding guidelines. We’ll get to those in a bit, but first let’s look at why they changed.
Pseudoseizures are a form of non-epileptic seizure. These are difficult to diagnose and oftentimes extremely difficult for the patient to comprehend. The term “pseudoseizures” is an older term that is still used today to describe psychogenic nonepileptic seizures (PNES).
With the implementation of ICD-10-CM came different codes and coding rules for many diagnoses. One of these is the coding of bowel obstruction when the patient presents for this condition that is caused by another condition.
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.
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.