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.
Examples:
- 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.
References
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
mayfieldclinic.com/pe-decompression.htm
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
Popular Posts
Coding Tip: Cardiac Catheterization Coding in ICD-10-PCS
With the implementation of ICD-10-PCS the description of codes became much more detailed to describe exactly what is being performed. Cardiac catheterization is one of the descriptions that changed to further detail exactly what is being performed during the procedure.
Part 1: CPT Breast Education Series | Overview of Breast Reconstruction
This is Part 1 of a 6-part series focusing on CPT coding of reconstructive procedures following mastectomy. There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders. Part 1 is an overview of the types of breast reconstruction techniques commonly used. Future topics in this series will go into more detail of each technique and the CPT coding implications.
ICD-10 Codes for Your Favorite Christmas Movies
With Christmas fast-approaching, we’re making a list of our favorite holiday movies and checking it twice. And in the spirit of good humor and cheer, we’ve added some ICD-10 codes to these holiday classics. Have a safe, happy, and healthy holiday everyone!
Coding Tip: Coding Lobar Pneumonia
“Lobar” pneumonia references a form of pneumonia that affects a specific lobe or lobes of the lung. This is a bacterial pneumonia and is most commonly community acquired. Antibiotics are almost always necessary to clear this type of pneumonia.
Part 5: Sepsis Series | Reasons for Denials and Prevention
Why are so many sepsis records denied? It’s hard to say why there seem to be so many sepsis denials of late, but most likely this is due to the multiple sets of criteria for the diagnosis of sepsis, change in definition of sepsis, as well as physician documentation.
Subscribe to our weekly newsletter
Latest News
Coding Tip: Cardiac Catheterization Coding in ICD-10-PCS
With the implementation of ICD-10-PCS the description of codes became much more detailed to describe exactly what is being performed. Cardiac catheterization is one of the descriptions that changed to further detail exactly what is being performed during the procedure.
Part 1: CPT Breast Education Series | Overview of Breast Reconstruction
This is Part 1 of a 6-part series focusing on CPT coding of reconstructive procedures following mastectomy. There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders. Part 1 is an overview of the types of breast reconstruction techniques commonly used. Future topics in this series will go into more detail of each technique and the CPT coding implications.
ICD-10 Codes for Your Favorite Christmas Movies
With Christmas fast-approaching, we’re making a list of our favorite holiday movies and checking it twice. And in the spirit of good humor and cheer, we’ve added some ICD-10 codes to these holiday classics. Have a safe, happy, and healthy holiday everyone!
Coding Tip: Coding Lobar Pneumonia
“Lobar” pneumonia references a form of pneumonia that affects a specific lobe or lobes of the lung. This is a bacterial pneumonia and is most commonly community acquired. Antibiotics are almost always necessary to clear this type of pneumonia.
Part 5: Sepsis Series | Reasons for Denials and Prevention
Why are so many sepsis records denied? It’s hard to say why there seem to be so many sepsis denials of late, but most likely this is due to the multiple sets of criteria for the diagnosis of sepsis, change in definition of sepsis, as well as physician documentation.
Part 4: Sepsis Series | Are Clinical Indicators Present to Support the Diagnosis of Sepsis?
In Parts 1, 2 and 3 we learned about what sepsis is, sequencing of sepsis and what documentation is needed to report severe sepsis. In Part 4, we will look at clinical indicators needed to clinically support the diagnosis of sepsis and determine if a query is indicated.
Part 3: Sepsis Series | Severe Sepsis Documentation and Reporting
Severe sepsis occurs when sepsis progresses and signs of organ dysfunction/failure develop. One site stated that approximately 30% of patients with severe sepsis do not survive. Patients may develop one organ dysfunction/failure, multi-system organ failure and/or septic shock.
Part 2: Sepsis Series | Sequencing the Diagnosis of Sepsis
In Part 2 of our Sepsis Series, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
Part 1: Sepsis Series | What is Sepsis?
In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
Part 4: New ICD-10 Codes and IPPS Changes
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 FY2020 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2020.
Part 3: New ICD-10 Codes and IPPS Changes
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 FY2020. On August 2, 2019, CMS published the Final Rule for IPPS (CMS-1716) FY2020 IPPS Final Rule.
Part 2: New ICD-10 Codes and IPPS Changes
In Part 1 of this 4 part series we discussed some of the new ICD-10-CM diagnosis changes. In Part 2 we present the significant ICD-10-PCS procedure code changes. There are 72,184 total ICD-10-CM codes for FY2020.
Part 1: New ICD-10 Codes and IPPS Changes
This is Part 1 of a 4 part series on the FY2020 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. There are 72,184 total ICD-10-CM codes for FY2020.
Part 14: Spinal Fusion Coding — Spinal Fusion Series Summary
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/.
Part 13: Spinal Fusion Coding — Harvesting of Autograft for Spinal Fusion
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
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
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
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 8: Spinal Fusion Coding — Discectomy During Spinal Fusion
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
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
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
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
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 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.
Part 2: Spinal Fusion Coding — Initial Fusion or Refusion
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
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
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
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
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.