Part 14: Spinal Fusion Coding — Spinal Fusion Series Summary

by hiacodeOct 9, 2019Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding0 comments

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.

View Parts 1-13 here: https://www.hiacode.com/topics/series/spinal-fusion-coding/

Spinal Fusion Series Summary

Most common diagnosis associated with the need for spinal fusion:

Degenerative disc disease/degeneration
Spinal stenosis/neurogenic claudication
Spondylolisthesis
Herniated disc/slipped disc/ruptured disc
Scoliosis/lordosis/kyphosis
Radiculopathy/pinched spinal nerve
Myelopathy
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

Happy Coding!

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.

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