Solidify inpatient spinal fusion coding

Spinal fusion is a procedure to join, or fuse, two or more vertebrae. The surgeon places bone or a bone-like material within the space between two spinal vertebrae. The surgeon may use metal plates, screws, and rods to hold the vertebrae together so they can heal into one solid unit.

 

Spinal fusion procedures can be performed in both the inpatient and outpatient settings. For outpatient procedures, coders use CPT^® codes. For inpatient procedures, coders currently use ICD-9-CM Vol. 3 codes and will use ICD-10-PCS codes after October 1, 2015.

 

Before coding for spinal procedures, coders need to make sure they understand the anatomy of the spine, says Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer, of Safian Communications Services in Orlando, Florida.

 

The spinal column is separated into five areas, based on location from the top of the spine to the bottom:

Each vertebra includes a vertebral body that surrounds the spinal cord to protect it in the front. The spinous process and the pedicle protect the spinal cord in the back. The pedicles are short, stout processes that attach to the superior part of the vertebral body on each side. These extend posteriorly to meet the laminae, which are broad flat plates of bone. The pedicles also overlap the laminae of the vertebrae below.

 

The articular processes arise from the junctions of the pedicles and laminae. These bony projections have a small, smooth surface known as a facet. Each vertebra includes four articular processes, two upper and two lower, that comprise the facet joints.

 

Coders also need to understand the difference between an interspace and a segment. A vertebral segment represents a single complete vertebral bone with its associated articular processes and laminae.

 

The vertebral interspace is the non-bony compartment between two adjacent vertebral bodies that contains the intervertebral disc, which includes the nucleus pulposus, annulus fibrosus, and two cartilaginous endplates.

 

ICD-9-CM Vol. 3 includes different codes for the different spinal levels and for fusion and refusion procedures.

 

Spinal fusions are classified by the anatomic portion fused and the technique (approach) used. For the anterior column, the body of the adjacent vertebrae are fused. This is called an interbody fusion. The surgeon can perform an interbody fusion using an anterior, posterior, or lateral technique.

For the posterior column, the surgeon fuses the posterior structures (laminae, pedicle, facet, transverse process) of adjacent vertebrae. The surgeon can use a posterior, posterolateral, or lateral transverse approach.

 

When coding for inpatient spinal fusion procedures in ICD-9-CM Vol. 3, coders need to identify:

The ICD-9-CM Vol. 3 code descriptors include the vertebral location, the area of the column, and the technique (approach). For example, if the surgeon performs a fusion of C1-C2 using an anterior approach, report 81.01.

 

Coders can also report insertion of the interbody fusion device using ICD-9-CM Vol. 3 code 84.51.

If the surgeon inserts recombinant bone morphogenetic protein (genetically engineered protein) , also report code 84.52.

 

Coders should also report a code from 81.62-81.64 to specify the number of vertebrae fused. Coders should only report one code from this series even if the surgeon fused vertebrae at different levels.

 

In ICD-10-PCS, coders will use root operation Fusion (joining together portions of an articular body part rendering the articular body part immobile) when the surgeon performs a spinal fusion. Spinal fusion procedures are reported using two different ICD-10-PCS tables, depending on the location of the vertebrae fused.

 

For occipital-cervical, cervical, cervicothoracic, thoracic, and thoracolumbar vertebral joints, coders will use table 0RF (fusion of upper joints). For lumbar vertebrae, coders will use table 0SF (fusion of lower joints).

 

ICD-10-PCS includes specific guidelines for coding spinal fusion procedures, including guidelines for selecting the body part value, says Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, MCP, director of auditing and CDI services for TrustHCS in Springfield, Missouri.

 

ICD-10-PCS guideline B310a states:

 

“Now, if multiple vertebral joint are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or a different qualifier,” Dominesey says. “When we look at the coding table, we’ll be able to see that.”

 

For example: 

Coders also need to pay attention to guideline B3.10c, which states:

 

 

 

 

“Something interesting to remember about spinal fusions is the different approaches,” Dominesey says. A physician may be working on the anterior column or the posterior column of the spinal column.

 

“But you need to not depend on the approach, because they could be doing a posterior approach and reaching around to work on the anterior column," Dominesey says. "They could be doing a lateral approach to be reaching through and working on both the anterior column, which will be the column that faces the front, or the posterior column, which would be the back.”

 

Coders need to look to see how the patient is positioned, Dominesey says. If the patient is positioned face down, the physician is using a posterior approach. In the majority of cases, that means the physician will be working on the posterior column. 

 

The anterior column is usually a stronger fusion mechanism because of the amount of vascular tissue that’s in the anterior column fusion and amount of nerves and blood supply impacted, Dominesey says. 

“Be mindful that the approach is not going to tell you exactly which column that the physician is operating on,” Dominesey says. “Be very careful when you read that operative report.”

 

The approach (fifth character) in the ICD-10-PCS Fusion table represents the surgical approach:

The qualifier (seventh character) specifies the approach and column. For example, in table 0RF, coders will choose between:

The ICD-10-PCS tables also specify the type of fusion device (sixth character) the surgeon uses. For upper vertebral joints, coders will choose from these devices:

If the physician performs a synchronous excision of locally harvested bone graft, report the procedure separately using root operation Excision, Dominesey says. If the physician inserts recombinant bone morphogenetic protein (genetically engineered protein) to help create a bone graft substitute, assign code 3E0V3GB (introduction of recombinant bone morphogenetic protein into bones, percutaneous approach).