Part 14: Spinal Fusion Coding — Spinal Fusion Series Summary

by hiacode | Oct 9, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding | 0 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.

Part 13: Spinal Fusion Coding — Harvesting of Autograft for Spinal Fusion

Oct 7, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, 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.

Part 12: Spinal Fusion Coding — Intra-Operative Peripheral Neuro Monitoring

Oct 4, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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.

Part 11: Spinal Fusion Coding — Computer Assisted Navigation

Oct 2, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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.

Part 10: Spinal Fusion Coding — Removing Hardware from Previous Fusion

Sep 30, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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.

Part 9: Spinal Fusion Coding — Was A Decompression Done During Spinal Fusion?

Sep 27, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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?

Part 8: Spinal Fusion Coding — Discectomy During Spinal Fusion

Sep 25, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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.

Part 7: Spinal Fusion Coding — Identify Any Instrumentation or Device Used

Sep 23, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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.

Part 6: Spinal Fusion Coding — Identify the Type of Bone Graft Used for Fusion

Sep 20, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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.

Part 5: Spinal Fusion Coding — Identifying the Approach Being Used for Fusion

Sep 18, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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).

HIA Launches Buddy Up Program for New Hires

Sep 17, 2019 | HIA News, Staff News

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.

Part 4: Spinal Fusion Coding — Identifying the Column Being Fused

Sep 16, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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

Sep 13, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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.

Part 2: Spinal Fusion Coding — Initial Fusion or Refusion

Sep 11, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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.”

Part 1: Spinal Fusion Coding — Diagnoses Responsible

Sep 9, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding

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.

What’s the Best Defense? A Good Offense

Aug 28, 2019 | Coding Review, Education, TCHT

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.

Query Tip: Writing a Query Question – Simple and Concise is the Key

Aug 23, 2019 | Beth Martilik, Education, Query Tip

The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.

Coding Tip: Coding Complications of Transplanted Organs

Aug 16, 2019 | Coding Tips, Education, ICD-10, Kim Carrier

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.

Find Your Routine: Take Advantage of Educational Opportunities

Aug 14, 2019 | Education, Find Your Routine, ICD-10, Series

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.

Coding Tip: Atrial Fibrillation

Aug 2, 2019 | Coding Tips, Education, ICD-10, Kim Carrier

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.

Coder Q&A with Pat Macc: Mucoid Casts and Mucus Plugs

Jul 31, 2019 | Education, ICD-10, Patricia Maccariella-Hafey, Q&A

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?

Query Tip: How to Be More Efficient

Jul 26, 2019 | Beth Martilik, Education, Query Tip

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.

Coder Q&A with Pat Macc: Metastatic Cancer

Jul 23, 2019 | Education, ICD-10, Patricia Maccariella-Hafey, Q&A

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)?

Coding Tip: Root Operation Selection Excision vs. Resection

Jul 19, 2019 | Coding Tips, Education, ICD-10, Kim Carrier

Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.

Find Your Routine: Be Flexible, Not Frustrated

Jul 8, 2019 | Education, Find Your Routine, ICD-10, Series

We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.

Coding Tip: Periprosthetic Fracture Reporting and Sequencing

Jun 28, 2019 | Coding Tips, Education, ICD-10, Kim Carrier

Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.

OIG Takes Notice of Coding Errors

Jun 26, 2019 | Coding Review, Education, TCHT

Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.

Coder Q&A with Pat Macc: Coding for Newborn

Jun 25, 2019 | Education, ICD-10, Patricia Maccariella-Hafey, Q&A

There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?

Query Tip: When to Query for Sepsis

Jun 21, 2019 | Beth Martilik, Education, Query Tip

Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?

Coder Q&A with Pat Macc: Principal Dx Selection

Jun 19, 2019 | Education, ICD-10, Patricia Maccariella-Hafey, Q&A

In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?