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.
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