Part 9: Spinal Fusion Coding — Was A Decompression Done During Spinal Fusion?
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
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?
What does decompression mean when performed in spinal surgery?
Decompression is the release of pressure on a spinal nerve root or on the spinal cord itself. Decompression is necessary when patients develop radiculopathy and/or myelopathy due to spinal disease. By releasing the herniated disc or other spinal condition that is irritating or pinching the nerve, the nerves are freed and should relieve the pain (radiculopathy/myelopathy) associated with this.
How do I know if it is spinal nerve or spinal cord being released?
In the perfect world of coding the surgeon will provide detailed and specific documentation on what is being released. However, we know that this is not always the case. Look for terms such as release, laminectomy, or decompression in the procedure note. When coding, if the patient has a diagnosis of spinal stenosis, claudication, radiculopathy or myelopathy and is undergoing spinal surgery, chances are that a release of the spinal nerve, spinal cord or both will be completed. If central decompression is documented in the operative note, this is referring to spinal cord and not the nerve. The same for thecal sac decompression. The body part for the thecal sac is also spinal cord. By decompressing the spinal nerve or spinal cord, the surgeon is opening up and creating more space in the affected area.
Can both spinal nerve and spinal cord be coded and how many times?
When reading the operative note, the coder should identify the spinal level being released (cervical, thoracic, lumbar or sacral). The code assignment depends on the site of the release and what is being released. Remember, the definition of release when coding in ICD-10-PCS is “freeing a body part from an abnormal physical constraint by cutting or by use of force.” The body part value for the ICD-10-PCS code would be the body part being freed and NOT to the tissue being moved/excised to free the body part.
If both, spinal nerves and spinal cord are released, both should be coded.
- Patient presents for spinal fusion of the L3-L5 spine with associated myelopathy and neurogenic claudication from severe lumbar herniated disc. During the procedure the surgeon identifies the herniated disc to be pressing against the nerves at L4-L5. The physician removes the portion of the disc that was pressing the nerve to obtain decompression in this area. The surgeon also performed central decompression of L3-L5 due to impingement of the spinal cord in this area. In this case, an ICD-10-PCS code would be assigned for the lumbar spinal nerve release/decompression as well as one for the lumbar spinal cord release/decompression at the same level in addition to the spinal fusion codes.
- Patient presents for spinal fusion due to lumbar spinal stenosis with severe degeneration of the spine as well as a ruptured disc. The operative note states that the surgeon performed a decompression of the L4-S1 spinal nerve roots as well as a central decompression at the same levels. In this case, ICD-10-PCS codes would be assigned for the lumbar spinal nerve release/decompression as well as the sacral nerve for the decompression of the spinal nerve roots at two levels (lumbar and sacral). An additional ICD-10-PCS code should also be reported for the central decompression (release of spinal cord) at the lumbar level.
View parts 1-8 of this series here: hiacode.com/topics/series/spinal-fusion-coding/.
Be on the lookout for Part 10 which will discuss removing hardware from a previous fusion site.
Coding Clinic for ICD-10-CM/PCS, First Quarter 2019: Page 28-30
Coding Clinic for ICD-10-CM/PCS, Second Quarter 2018: Page 22
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2018: Page 30
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.
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/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.
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.
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.
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.
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.
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.
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.
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).
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.
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
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.
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.”
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.
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.
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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.
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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.
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.
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.
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.
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?
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?
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?