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.
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