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.

Download 14-Part Series

DOWNLOAD

Coding Tip: Sneak Peek at FY2022 ICD-10-PCS Procedure Additions and Changes

Jul 22, 2021

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.

Coding Tip: Sneak Peek at FY2022 Proposed DRG Changes

Jun 14, 2021

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.

What to Consider Before Your Next Coding Audit

May 19, 2021

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…

Coding Tip: Anticoagulation and Antiplatelet Therapy

May 6, 2021

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.

Coding Tip: Carotid Artery Disease

Apr 29, 2021

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.



Subscribe to our weekly newsletter

Coding Tip: Sneak Peek at FY2022 ICD-10-PCS Procedure Additions and Changes

Jul 22, 2021 | Coding Tips, Education, ICD-10, Patricia Maccariella-Hafey

Coding Tip: Sneak Peek at FY2022 Proposed DRG Changes

Jun 14, 2021 | Coding Tips, Education, ICD-10, Patricia Maccariella-Hafey

What to Consider Before Your Next Coding Audit

May 19, 2021 | Coding Review, Coding Support, Education

Coding Tip: Anticoagulation and Antiplatelet Therapy

May 6, 2021 | Coding Tips, Education, ICD-10, Kim Carrier

Coding Tip: Carotid Artery Disease

Apr 29, 2021 | Coding Tips, Education, ICD-10, Kim Carrier

National Superhero Day: ICD-10 Codes for Superheroes

Apr 27, 2021 | Coding Review, Coding Support, Education

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…

Overview of the 2021 E/M Guideline Coding Changes

Apr 19, 2021 | Coding Review, Coding Support, Education

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.

Coding Tip: Understanding and Reporting Pseudoseizures

Apr 15, 2021 | Coding Tips, Education, ICD-10, Kim Carrier

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).

Coding Tip: Coding Bowel Obstruction in ICD-10-CM

Apr 8, 2021 | Coding Tips, Education, ICD-10, Patricia Maccariella-Hafey

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.

Part 5: New 2021 CPT Codes | Modifiers, Category III, Evaluation and Management, etc.

Feb 17, 2021 | 2021 New CPT Codes, CPT, Education, Patricia Maccariella-Hafey, Series

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.

Part 4: New 2021 CPT Codes | Urinary, Nervous, Ocular and Auditory Systems

Feb 10, 2021 | 2021 New CPT Codes, CPT, Education, Patricia Maccariella-Hafey, Series

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.

Part 3: New 2021 CPT Codes | Cardiovascular System

Feb 2, 2021 | 2021 New CPT Codes, CPT, Education, Patricia Maccariella-Hafey, Series

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.

Part 2: New 2021 CPT Codes | Musculoskeletal and Respiratory Systems

Jan 27, 2021 | 2021 New CPT Codes, CPT, Education, Patricia Maccariella-Hafey, Series

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.

Part 1: New 2021 CPT Codes | Integumentary System

Jan 19, 2021 | 2021 New CPT Codes, CPT, Education, Patricia Maccariella-Hafey, Series

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.

2020: Year in Review | Coding Education

Dec 29, 2020 | Coding Review, Coding Support, Coding Tips, Coronavirus, COVID-19, CPT, Education, ICD-10, Outpatient, Patricia Maccariella-Hafey

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.

Coding Tip: New COVID-19 Codes Effective January 1, 2021

Dec 2, 2020 | Coding Tips, Coronavirus, COVID-19, Education, ICD-10, Patricia Maccariella-Hafey

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.

New Technology Add-On Payments (NTAP) For FY2021 – Part 4

Oct 28, 2020 | Coding Tips, Education, ICD-10, IPPS, IPPS 2021, Patricia Maccariella-Hafey

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.

New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 3

Oct 26, 2020 | Coding Tips, Education, ICD-10, IPPS, IPPS 2021, Patricia Maccariella-Hafey

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.

New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 2

Oct 23, 2020 | Coding Tips, Education, ICD-10, IPPS, IPPS 2021, Patricia Maccariella-Hafey

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)…

New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 1

Oct 20, 2020 | Coding Tips, Education, ICD-10, IPPS, IPPS 2021, Patricia Maccariella-Hafey

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)

Coding Tip: Reporting “Flash” Pulmonary Edema

Oct 5, 2020 | Coding Tips, Education, ICD-10, Kim Carrier

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: $556 increase/record reviewed

Oct 1, 2020 | Coding Review, Education

“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.

Coding Tip: Glasgow Coma Scale Coding OCG Update for FY2021

Sep 29, 2020 | Coding Tips, Education, ICD-10, Patricia Maccariella-Hafey

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.

Client X: Let’s Talk Numbers

Sep 15, 2020 | Coding Review, Education

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.

Coding Tip: Endarterectomy During Coronary Artery Bypass

Sep 10, 2020 | Coding Tips, Education, ICD-10, Kim Carrier

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.

Coding Tip: Update – Coding COVID-19 When the Test is Negative

Aug 6, 2020 | Coding Tips, Coronavirus, COVID-19, Education, ICD-10, Patricia Maccariella-Hafey

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.

New ICD-10-PCS Procedure Codes for COVID-19

Aug 4, 2020 | Coding Tips, Coronavirus, COVID-19, Education, ICD-10, Patricia Maccariella-Hafey

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.

New Rule Helps Medicare ACOs During COVID-19 Pandemic

Jul 1, 2020 | Coding Tips, Coronavirus, COVID-19, Education, ICD-10

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.

Part 5: Reasons for AKI Denials and Prevention | AKI Series

May 22, 2020 | Acute Kidney Injury (AKI), Coding Tips, Education, ICD-10, Kim Carrier

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.