Spinal Procedure Coding in ICD 10 Linda Dawson

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Spinal Procedure Coding in ICD 10 Linda Dawson, RHIT, CCS, I-10 CM/PCS Trainer IP

Spinal Procedure Coding in ICD 10 Linda Dawson, RHIT, CCS, I-10 CM/PCS Trainer IP Coding QI Compliance Auditor and Trainer

Functions of the vertebral column Protection: Encloses and protects the spinal cord within the

Functions of the vertebral column Protection: Encloses and protects the spinal cord within the spinal canal. Support: Carries the weight of the body above the pelvis. Axis: Forms the central axis of the body. Movement: Has roles in both posture and movement.

Anatomy of the vertebrae (Spinous process) Pars interarticularis http: //spondo. weebly. com/uploads/1/7/1/6/17164828/7876864_orig. jpg? 1365377597

Anatomy of the vertebrae (Spinous process) Pars interarticularis http: //spondo. weebly. com/uploads/1/7/1/6/17164828/7876864_orig. jpg? 1365377597

Anatomy of the Vertebrae

Anatomy of the Vertebrae

Anatomy of the Vertebra

Anatomy of the Vertebra

Anatomy of the Vertebra

Anatomy of the Vertebra

Vertebral Terminology Body: The body is the largest part of a vertebra, it is

Vertebral Terminology Body: The body is the largest part of a vertebra, it is slightly cylindrical in shape, and faces interior of body. Its upper and lower surfaces are flattened and rough, and each presents a rim around its circumference. Foramen: A natural opening or passage, through a bone Pedicles: The pedicles are two short, thick processes, which project backward, one on either side, from the upper part of the body, at the junction of its posterior and lateral surfaces. The concavities above and below the pedicles are named the vertebral notches. Laminae: The laminae are two broad plates directed backward and medial ward from the pedicles. They fuse in the middle line posteriorly, and so complete the posterior boundary of the vertebral foramen. Spinous Processes: The spinous process is directed backward and downward from the junction of the laminae, and serves for the attachment of muscles and ligaments. Articular Processes: The articular processes, two superior and two inferior, spring from the junctions of the pedicles and laminae. The articular surfaces are coated with hyaline cartilage. Transverse Processes: The transverse processes, two in number, project one at either side from the point where the lamina joins the pedicle.

Diagnoses for Spinal Fusions • • • Spondylolisthesis – forward displacement of one vertebra

Diagnoses for Spinal Fusions • • • Spondylolisthesis – forward displacement of one vertebra over another, usually of the fifth lumbar over the body of the sacrum, or of the fourth lumbar over the fifth, usually due to a developmental defect in the pars interarticularis. Spondylosis – (arthritis) with or without myelopathy (any functional disturbance or pathological change in the spinal cord) or radiculopathy (disorder of the spinal nerve roots) Degenerative Disc Disorders (DDD) with or without myelopathy or radiculopathy Spinal instability – unstable spine due to disc disorders Stenosis – narrowing of the vertebral canal, nerve root canals, or intervertebral foramina of the lumbar spine, caused by encroachment of bone upon the space; symptoms are caused by compression of the cauda equina and include pain, paresthesias, and neurogenic claudication. The condition may be either congenital or due to spinal degeneration. o Spinal cord M 48 -o Neural canal – nerve M 99. 5 - ** spinal stenosis is coded in I-10, whereas it was not coded in I-9. ** There is no code for neurogenic claudication in I-10. (per 3 M) 2018 Codes will include specificity of “neurogenic claudication. ”

Scoliosis > Narrowing of thoracic cage leading to abnormal cardiovascular and pulmonary function Complications

Scoliosis > Narrowing of thoracic cage leading to abnormal cardiovascular and pulmonary function Complications of scoliosis: > Restrictive lung disease, dyspnea on exertion, pulmonary hypertension, cor pulmonale, and alveolar hypoventilation Congenital scoliosis is a cc Q 67. 5 https: //image. slidesharecdn. com/anesthesiaforspinalcordinjuryandscoliosis 030 -120519234731 phpapp 02/95//anesthesia-for-spinal-cord-injury-and-scoliosis 030 -16 -728. jpg? cb=1337471395

Synovial Cyst of Spine A synovial cyst of the spine is a fluid-filled sac

Synovial Cyst of Spine A synovial cyst of the spine is a fluid-filled sac that develops along the spine. It’s the result of degeneration of a facet joint of the vertebrae of the spine. Most synovial cysts develop in the lumbar spine. M 71. 38, Other bursal cyst, other site

Preexisting/Spinal related MCC/CC Diagnoses Vascular myelopathy MCC – G 95. 19 o An abnormality

Preexisting/Spinal related MCC/CC Diagnoses Vascular myelopathy MCC – G 95. 19 o An abnormality of the spinal cord in regard to its blood supply. Edema of the spinal cord – (vascular) (non-traumatic) o Hematomyelia o Nonpyogenic intraspinal phlebitis/thrombophlebitis o Subacute necrotic myelopathy Edema of the spinal cord due to trauma CC – S 340. 1 XA lumbar spinal cord o This could be due to a current injury of the spinal cord or late effect of trauma to the spinal cord. If spinal cord edema is documented with or without a previous spinal injury, query the physician to see if the edema is traumatic or nontraumatic and if the edema is considered to be clinically significant affecting patient care.

MCC Diagnoses G 95. 19 Edema of the spinal cord (vascular myelopathy) (nontraumatic) INDICATIONS:

MCC Diagnoses G 95. 19 Edema of the spinal cord (vascular myelopathy) (nontraumatic) INDICATIONS: This is a lady with progressive myelopathy. She has advanced degenerative changes throughout her cervical spine, but at C 4 -5 there is a bulging disc and compression of the spinal cord with some mild edema. Physiology: Cervical myelopathy begins with compression of the spinal cord in the cervical spine. Edema begins to build about the spinal cord as the cord attempts to protect itself. This edema appears as white in a t 2 -weighted MRI images. 3 M Response to question: I would recommend a query to the physician to determine if the spinal cord edema was clinically significant or an expected response from degenerative disk disease with myelopathy. The spinal cord edema would need to meet the criteria for reporting as a secondary diagnosis. In my opinion, a separate code (G 95. 19) for spinal cord edema would be appropriate if the edema was considered to be clinically significant; there are no exclusion notes regarding the assignment of codes from category M 51. - and G 95. 19.

CC Diagnoses Fracture of the vertebrae in a patient due to osteomyelitis: Fx –

CC Diagnoses Fracture of the vertebrae in a patient due to osteomyelitis: Fx – pathological M 84. 68 Osteomyelitis - CC Myelomalacia - CC Morbid softening of the spinal cord. Accidental pucture of the dura during a procedure G 97. 41

Coding Clinic Cervical Disc Disorders ICD-10 -CM/PCS Coding Clinic, First Quarter ICD-10 2016 Page:

Coding Clinic Cervical Disc Disorders ICD-10 -CM/PCS Coding Clinic, First Quarter ICD-10 2016 Page: 17 Effective with discharges: March 18, 2016 Question: The instructional note at category M 50, Cervical disc disorders states, "Code to the most superior level of disorder. " Coders at our facility are trying to interpret this instruction for assigning codes for cervical disc disorders. Does this directive apply only to adjacent levels? If several regions are affected, involving different levels (e. g. , C 3 -C 4 and C 5 -C 6), is the code for only the most superior level assigned or can both levels be coded? Answer: The intent of the note is to code each disorder at the highest (most superior) level. Each fourth digit subcategory describes a unique disorder, so within each subcategory, code to the highest level. For example, if several regions are affected (e. g. , C 3 -C 4 and C 5 -C 6) that are classified to the same subcategory (e. g. , M 50. 0), assign code M 50. 01, Cervical disc disorder with myelopathy, high cervical region, as C 3 -C 4 is the most superior level.

2018 ICD 10 -CM Code changes

2018 ICD 10 -CM Code changes

Neurogenic claudication A new code will be available to show spinal stenosis with neurogenic

Neurogenic claudication A new code will be available to show spinal stenosis with neurogenic claudication. M 48. 061 Spinal stenosis, lumbar region, without neurogenic claudication M 48. 062 Spinal stenosis, lumbar region, with neurogenic claudication

2018 DRG changes There will be DRG changes as a result of corrections to

2018 DRG changes There will be DRG changes as a result of corrections to the PCS code tables for fusions in 2018. Several spinal fusion levels listed “posterior column” portion of the spine as an option for fusion with interbody fusion devices. As we know the IBFD’s are only used on the anterior portion of the spine so the PCS code tables had errors which will now be corrected.

Spinal Fusions ICD 10 Procedure Classification System

Spinal Fusions ICD 10 Procedure Classification System

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Root Operation The Root Operation for Spinal Fusion is Fusion: Fusion (G) – Joining

Root Operation The Root Operation for Spinal Fusion is Fusion: Fusion (G) – Joining together portions of an articular body part rendering the articular body part immobile. The body part is joined together by fixation device, bone graft, or other means. Fusion procedures are only performed on joints.

ICD-10 -PCS Coding Guidelines Fusion procedures of the spine B 3. 10 a The

ICD-10 -PCS Coding Guidelines Fusion procedures of the spine B 3. 10 a The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e. g. thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level. Example: Body part values specify Lumbar Vertebral Joint, Lumbar Vertebral Joints, 2 or More and Lumbosacral Vertebral Joint.

What to Code Spinal Fusion Guideline – B 3. 10 B If multiple vertebral

What to Code Spinal Fusion Guideline – B 3. 10 B If multiple vertebral joints are fused a separate procedure is coded for each vertebral joint that used a different device and/or qualifier. Example: Fusion of lumbar vertebral joint, posterior approach, anterior column Fusion of lumbar vertebral joint, posterior The Qualifier is the approach approach, posterior column This example DRG 455 and the column, 2 codes for this example: 0 SG 00 A 0 0 SG 00 Z 1

Body Part Values Upper 7 cervical Cervicothoracic 12 thoracic 5 lumbar 2 sacral 1

Body Part Values Upper 7 cervical Cervicothoracic 12 thoracic 5 lumbar 2 sacral 1 coccyx Lumbar spine lumbosacral Lower Thoracolumbar

Upper Joints

Upper Joints

Lower Joints

Lower Joints

Incisions for the Procedure The (incisional) approach to the procedure is included in the

Incisions for the Procedure The (incisional) approach to the procedure is included in the 7 th character of the code. Anterior – front of body Posterior – back of body

7 th Character- Approach Portion of Spine Fused Posterior approach, Anterior column PLIF: Posterior

7 th Character- Approach Portion of Spine Fused Posterior approach, Anterior column PLIF: Posterior Lumbar Interbody Fusion TLIF: Transforaminal Lumbar Interbody fusion Anterior approach Anterior Column Posterior approach Posterior column XLIF: Extreme Lateral Interbody fusion DLIF: Direct Lateral Interbody Fusion Posterolateral Fusion Procedure are sometimes performed posterior approach on the anterior column

Qualifier Anterior Approach, Anterior Column: access through the front of the body to perform

Qualifier Anterior Approach, Anterior Column: access through the front of the body to perform a procedure in the body of the vertebrae or the disc. Posterior Approach, Posterior Column: access through the back of the body to perform a procedure on the vertebral foramen, spinous processes, facets, and or lamina. Posterior Approach, Anterior Column: access through the back of the body to perform a procedure on the body of the vertebrae or the disc.

Cervical and Thoracic Spinal Fusion ICD-10 -CM/PCS Coding Clinic, First Quarter 2013 Pages: 29

Cervical and Thoracic Spinal Fusion ICD-10 -CM/PCS Coding Clinic, First Quarter 2013 Pages: 29 -30 Effective with discharges: March 27, 2013 Question: A patient is diagnosed with C 7 -T 1 nucleus pulposus herniation with associated impingement upon the exiting left C 8 nerve root, and C 8 radiculopathy with associated weakness. Provider documentation indicates Smith-Robinson approach to the anterior cervical spine, discectomy, use of local autograft, placement of interbody allograft cage packed with DBX (demineralized bone matrix), placement of interbody spacer for arthrodesis, and placement of Vectra Synthes plate and screws instrumentation. What is the correct ICD-10 -PCS code for the spinal fusion? Answer: Assign code 0 RG 40 A 0, Fusion of cervicothoracic vertebral joint with interbody fusion device, Anterior approach, Anterior column, Open approach, for fusion of one joint between C 7 and T 1. "Cervicothoracic vertebral joint" is the distinct body part value for the single vertebral joint (C 7 -T 1) rendered immobile by the spinal fusion. "Interbody fusion device" is the device value, since interbody fusion devices (interbody spacer, interbody cage) and bone graft (local autograft) were used to render the joint immobile. Anterior approach anterior column is the qualifier, since "Smith-Robinson approach to the anterior cervical spine, C 7 -T 1 anterior cervical discectomy" is documented. ICD-10 -PCS Coding Guidelines B 3. 10 a states "the body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e. g. , thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level. " ICD-10 -PCS Coding Guidelines B 3. 10 c states "if an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device. "

Spinal Fusion of Thoracic and Lumbar Spine ICD-10 -CM/PCS Coding Clinic, First Quarter 2013

Spinal Fusion of Thoracic and Lumbar Spine ICD-10 -CM/PCS Coding Clinic, First Quarter 2013 Pages: 21 -23 Effective with discharges: March 27, 2013 Question: A patient is diagnosed with T 10 chronic burst fracture with subsequent kyphotic collapse resulting in myelopathy and severe myelopathy secondary to spinal cord injury. The procedure is listed as T 9, T 10, T 11 laminectomy, facetectomy, foraminotomy. A transpedicular approach to the T 10 vertebral body was used for spinal cord decompression. Instrumentation with pedicle screw and rod construct was placed from T 6, T 7, T 8, T 9, T 11, T 12, L 1 and L 2. Posterior arthrodesis of T 6, T 7, T 8, T 9, T 10, T 11, T 12, L 1 and L 2 was performed with use of local autograft and allograft. Provider documentation in the body of the operative report indicates arthrodesis, placement of all of the local autograft, as well as crushed cancellous allograft and bone morphogenetic protein (BMP). What are the correct ICD-10 -PCS codes for the number of interspaces fused? Answer: Assign the following ICD-10 -PCS codes: 0 RG 7071, Fusion of 2 to 7 thoracic vertebral joints with autologous tissue substitute, posterior approach, posterior column, open approach (fusion of 6 joints between T 6 and T 12)] The ICD-10 -PCS codes for spinal fusion are assigned based on the number of interspaces fused (i. e. , 2 -3, 4 -5, or 6 -7) rather site of the fusion. "Thoracic Vertebral Joints, 2 to 7, " is the distinct body part value for the 6 thoracic vertebral joints rendered immobile by the spinal fusion. "Posterior Approach, Posterior Column" is the qualifier, since provider documentation indicates transpedicular approach (posterolateral) and posterior arthrodesis (fusion). 0 RGA 071, Fusion of thoracolumbar vertebral joint with autologous tissue substitute, posterior approach, posterior column, open approach (fusion of one joint between T 12 and L 1) The "thoracolumbar vertebral joint, " is the distinct body part value for the vertebral joint between T 12 and L 1, rendered immobile by the spinal fusion. "Posterior Approach, Posterior Column" is the qualifier, since provider documentation indicates transpedicular approach (posterolateral) and posterior arthrodesis (fusion). "Autologous tissue substitute" is the device value, since a mixture of autograft, allograft and BMP were used to render all of the joints immobile.

Coding Tips for Spinal Fusions If multiple vertebral joints are fused, a separate procedure

Coding Tips for Spinal Fusions If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier. Detailed review of Operative Report will be necessary for accurate code assignment. If another surgical procedure is performed at the same time (another Root Operation or a different Body Part), be sure to code the other component. ü Example: Anterior cervical discectomy and fusion ü Example: Posterior lumbar fusion using bone graft taken from right iliac crest (hip bone)

Discectomy Two root operations: Excision Resection – complete – radical – total Check the

Discectomy Two root operations: Excision Resection – complete – radical – total Check the description in the operative report for wording which describes how much of the disc is removed

Coding Clinics 2 nd Q 2014, pages 6 -7 A: Discectomy is almost always

Coding Clinics 2 nd Q 2014, pages 6 -7 A: Discectomy is almost always performed at the same time as spinal fusion surgery. Typically, a fusion involves partial removal of the disc. If the provider performs a discectomy with spinal fusion, it should be coded as excision of disc. If, however, the provider documents “total discectomy” it should be coded as resection. In this case, assign the following ICD-10 -PCS codes. ***Discectomy will usually be performed at the same time as insertion of an interbody fusion device***

Coding Clinics 2 nd Q 2014, pages 6 -7 0 SG 107 J fusion

Coding Clinics 2 nd Q 2014, pages 6 -7 0 SG 107 J fusion of 2 lumbar vertebral joints with autologous tissue substitute, posterior approach, anterior column, open 0 SB 20 ZZ excision of lumbar vertebral disc, open 0 QB 20 ZZ excision of right pelvic bone (iliac crest), open

Anterior Cervical Thoracic Fusion with Total Discectomy ICD-10 -CM/PCS Coding Clinic, Second Quarter ICD-10

Anterior Cervical Thoracic Fusion with Total Discectomy ICD-10 -CM/PCS Coding Clinic, Second Quarter ICD-10 2014 Pages: 7 -8 Effective with discharges: May 26, 2014 Question: A patient is admitted for surgical treatment of herniated nucleus pulposus C 7 -T 1 with impingement on the nerve root, and radiculopathy. She underwent anterior cervical-thoracic spinal fusion, anterior approach, using interbody cage packed with demineralized bone matrix and autograft, and placement of plate and screw instrumentation with total discectomy. What is the correct ICD-10 -PCS code for the spinal fusion? Should the complete discectomy be coded separately? Answer: In this case, the provider documented "total discectomy. " Therefore it is coded as a resection. Assign ICD-10 -PCS procedure codes as follows: 0 RG 40 A 0 Fusion of cervicothoracic vertebral joint with interbody fusion device, anterior approach, anterior column, open approach, for fusion C 7 -T 1 0 RT 50 ZZ Resection of cervicothoracic vertebral disc, open approach, for the total discectomy Spinal fusion using an interbody cage containing demineralized bone matrix and autograft is coded to the device "Interbody Fusion Device. " Additionally, the fixation instrumentation (i. e. , rods, plates, screws, etc. ) is included in the fusion root operation, and no additional code is assigned

Spinal Fusion & Fixation Instrumentation http: //www. indiacarez. com/wp-content/uploads/2014/12/Spinal-Fusion-Surgery 1. jpg https: //www. medicaltourismco.

Spinal Fusion & Fixation Instrumentation http: //www. indiacarez. com/wp-content/uploads/2014/12/Spinal-Fusion-Surgery 1. jpg https: //www. medicaltourismco. com/wp-content/uploads/2014/10/cervical-disectomy. jpg http: //www. rexmarcomd. com/uploads/2013/03/Anterior-Cervical-Discectomy. jpg http: //orthoinfo. aaos. org/figures/A 00742 F 02. jpg https: //www. colourbox. com/preview/4146777 -surgeon. jpg

What Devices to Code Do Code: • Interbody Fusion Devices: (Cages/Spacers) ***do not code

What Devices to Code Do Code: • Interbody Fusion Devices: (Cages/Spacers) ***do not code the grafts used to fill the interbody fusion device. • Grafts: Autologous tissue – used in anterior/posterior fusion Non-autologous tissue - used in anterior/posterior fusion Synthetic tissue – in anterior/posterior fusion Do not code the following fixation devices: Rods **used to perform/reinforce fusion*** plates screws

Coding Clinics 3 rd Q 2014, page 30 Q: Please clarify whether a separate

Coding Clinics 3 rd Q 2014, page 30 Q: Please clarify whether a separate code is assigned for internal fixation/instrumentation (rods, screws, plates, etc. ) used with spinal fusion A: ICD-10 -PCS general guideline B 3. 1 b clarifies that components of a procedure specified in the root operation definition and explanation are not coded separately. The explanation for Fusion states “body part is joined together by fixation device, bone graft, or other means. ” Therefore, the fixation device is included in the fusion root operation, and no additional code is assigned.

Spinal Fusion and Fixation Instrumentation ICD-10 -CM/PCS Coding Clinic, Third Quarter ICD-10 2014 Pages:

Spinal Fusion and Fixation Instrumentation ICD-10 -CM/PCS Coding Clinic, Third Quarter ICD-10 2014 Pages: 30 -31 Effective with discharges: September 15, 2014 Related Information Question: Coding Clinic, First Quarter 2013, pages 29 -30, advised to assign code 0 RG 40 A 0, for interbody fusion of C 7 and T 1 with placement of Vectra Synthes plate and screws. Third Quarter 2013, pages 25 -26, advised to assign codes 0 SG 0071 and 0 SG 00 AJ for a 360 -degree interbody and autologous bone graft spinal fusion with placement of pedicle screws. Some coders disagree with this advice and feel that the plates and screws used during spinal fusion should be coded separately, since different root operations are utilized. The procedure appears to meet guideline B 3. 2 c (multiple root operations with distinct objectives are performed on the same body part). Please clarify whether a separate code is assigned for internal fixation/instrumentation (rods, screws, plates, etc. ) used with spinal fusion. Answer: ICD-10 -PCS general guideline B 3. 1 b, clarifies that components of a procedure specified in the root operation definition and explanation are not coded separately. The explanation in the root operation for fusion states "that body part is joined together by fixation device, bone graft, or other means. " Therefore, the fixation (rods, plates, screws) is included in the fusion root operation, and no additional code is assigned.

Interbody Devices Cages or Spacers (PEEK) Other devices including the Titan Nanolock These substances

Interbody Devices Cages or Spacers (PEEK) Other devices including the Titan Nanolock These substances can be used to pack the cages but will not be coded: (Code the cage only) Demineralized Bone Matrix Autologous or Non-Autologous Bone Grafts BMP (Bone Morphogenetic Protein)

PEEK Cages/Spacers

PEEK Cages/Spacers

Substances for Fusions These substances can be used to fuse the posterior spine: Autologous

Substances for Fusions These substances can be used to fuse the posterior spine: Autologous Graft from the patient’s own bone Non-Autologous Tissue Substitute – from a bone bank – cancellous chips Synthetic – Mastergraft, BMP

Coding Guidelines Spinal Fusion Guideline – B 3. 10 C Code Details – Device

Coding Guidelines Spinal Fusion Guideline – B 3. 10 C Code Details – Device (when combinations of devices and materials are used): If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with Device = Interbody Fusion Device If bone graft is the only device used to render the joint immobile, the procedure is coded with Device = Nonautologous Tissue Substitute or Autologous Tissue Substitute If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with Device = Autologous Tissue Substitute Autologous: If autologous, and either non-autologous or synthetic = autologous Non-autologous If non-autologous and synthetic = non-autologous Synthetic

Coding Tips for Spinal Fusions Fixation instrumentation (rods, plates, screws) done along with fusion

Coding Tips for Spinal Fusions Fixation instrumentation (rods, plates, screws) done along with fusion (interbody device, bone grafts) is included in the Fusion root operation and no additional code is assigned. This is to hold it in place while the fusion heals. Fixation instrumentation done on other vertebral levels not fused, will be coded using the root operation of Insertion. Bone morphogenetic protein (BMP) utilized in a fusion is included in the Fusion root operation no additional code is assigned. This is captured in the device character.

Titan Nanolock Device Add on Technology codes This device is used in place of

Titan Nanolock Device Add on Technology codes This device is used in place of the cages in an anterior fusion Example: XRG 1092 Cervical fusion You do not code a separate code for the anterior fusion.

Titan Nanolock Device We found that the use of the XRG code can group

Titan Nanolock Device We found that the use of the XRG code can group these procedures to the incorrect DRG. When performed with a posterior fusion, they are grouping incorrectly. CMS is working on resolving the DRG issues associated with coding these devices in Version 35. ~ 3 M January 2017 https: //www. cms. gov/ICD 10 Manual/version 34 -fullcode-cms/fullcode_cms/P 0182. html

Incorrect DRG Grouping with the Titan Nanolock Device

Incorrect DRG Grouping with the Titan Nanolock Device

What it Should be….

What it Should be….

Refusions What to code when a refusion is performed at a different level from

Refusions What to code when a refusion is performed at a different level from previous fusion Diagnosis: Code reason for refusion Code Arthrodesis Z 98. 1 Procedures: Code removal of fixation devices Code new fusion and other procedures performed Example: Fx of the pedicle of L 5 due to the fixation device (screw) Previous fusion of L 4 -5 with rod from L 3 -5 Removal of rod from L 3 -L 5 – removal of fixation device Fusion of L 5 -S 1 – New fusion with new rod stated below. Reinsertion of the rod from L 3 -S 2 Insertion of Rod from L 5 to S 1 without fusion Make sure to code removal of any fixation device which is replaced to perform the new fusion

Release Spinal Cord Vs. Release of Spinal Nerve

Release Spinal Cord Vs. Release of Spinal Nerve

Spinal Stenosis Spinal stenosis is an abnormal narrowing (stenosis) of the spinal canal that

Spinal Stenosis Spinal stenosis is an abnormal narrowing (stenosis) of the spinal canal that may occur in any of the regions of the spine. This narrowing causes a restriction to the spinal canal, resulting in a neurological deficit. Symptoms include pain, numbness, paraesthesia, and loss of motor control.

Spinal stenosis/Spinal nerve compression https: //www. spineuniverse. com/sites/default/files/ legacy-images/wu_nerve_compression 400 -AA. jpg http: //www.

Spinal stenosis/Spinal nerve compression https: //www. spineuniverse. com/sites/default/files/ legacy-images/wu_nerve_compression 400 -AA. jpg http: //www. sycamorept. com/wp-content/uploads/spinal-stenosis. jpg

Decompression of nerve root Spinal nerve root decompression Laminectomy, laminotomy facetectomy, and/or foraminotomy can

Decompression of nerve root Spinal nerve root decompression Laminectomy, laminotomy facetectomy, and/or foraminotomy can done to “Release” the nerve. https: //s-media-cache-ak 0. pinimg. com/originals/c 8/c 4/84/c 8 c 484656 cbeb 153146 ae 335 d 16 bc 71 d. gi f

Example of Release Spinal Nerve Pre-op diagnosis: spondylosis of L 3 -4 with radiculopathy

Example of Release Spinal Nerve Pre-op diagnosis: spondylosis of L 3 -4 with radiculopathy Procedure: Laminectomy of L 3 -4 Description: Decompression foraminotomy and laminectomy were performed with nerve roots decompressed. Correct Code: Release of the lumbar 3 -4 nerve root 01 NB 0 ZZ

Decompressive Laminectomy Clarification ICD-10 -CM/PCS Coding Clinic, Second Quarter ICD-10 2015 Page: 34 Effective

Decompressive Laminectomy Clarification ICD-10 -CM/PCS Coding Clinic, Second Quarter ICD-10 2015 Page: 34 Effective with discharges: July 6, 2015 Question: The patient presents for decompressive lumbar laminectomy. The surgeon performed an open complete decompressive laminectomy of L 3 -L 4, as well as superior partial laminectomy of L 5, and inferior partial laminectomy of L 2. What is the appropriate root operation, "Excision" or "Release"? How is this surgery coded in ICD-10 -PCS? Answer: Decompressive laminectomy is done to release pressure and free up the spinal nerve root. Therefore the appropriate root operation is "Release. " Assign the following ICD-10 -PCS code 01 NB 0 ZZ Release lumbar nerve, open approach

Removal of longitudinal ligament to release the cervical nerve

Removal of longitudinal ligament to release the cervical nerve

Removal of longitudinal ligament to release the cervical nerve

Removal of longitudinal ligament to release the cervical nerve

Decompressive Laminectomy/Foraminotomy and Lumbar Discectomy Question: The patient presents for surgery due to lumbar

Decompressive Laminectomy/Foraminotomy and Lumbar Discectomy Question: The patient presents for surgery due to lumbar disc herniation, foraminal stenosis and degenerative scoliosis refractory to conservative treatment. She underwent lateral microdiscectomy, L 2 -L 3 and L 3 -L 4, using intraoperative fluoroscopy. During surgery, disc material displacing the L 2 -L 3 and L 3 -L 4 nerve roots was excised. Foraminotomy was then accomplished by resecting portions of the lamina to decompress the region. Should the decompressive foraminotomy/laminectomy be coded along with the discectomy? Answer: The lumbar disc herniation and foraminal stenosis are separate and distinct diagnoses, and both were surgically treated. Decompressive foraminotomy/laminectomy was done to treat the foraminal stenosis by releasing pressure and freeing up the spinal nerve root, whereas the discectomy was performed to treat the lumbar disc herniation. Each surgery had distinct procedural objectives and should be separately coded. The appropriate root operations are "Excision" and "Release. " Assign the following ICD-10 -PCS codes: 0 SB 20 ZZ Excision of lumbar vertebral disc, open approach 01 NB 0 ZZ Release lumbar nerve, open approach

Compression Spinal Cord Release of spinal cord performed for myelopathy Release of nerve root

Compression Spinal Cord Release of spinal cord performed for myelopathy Release of nerve root performed for radiculopathy

Decompression spinal cord Central decompression of the foramina Laminectomy, laminotomy facetectomy, foraminotomy, and/ or

Decompression spinal cord Central decompression of the foramina Laminectomy, laminotomy facetectomy, foraminotomy, and/ or discectomy can be done for the “Release” of the spinal cord for myelopathy. http: //cdn. c. photoshelter. com/img-get/I 0000 pn. Xm. Rr. RZt 0 Q/s/600/85712 DS. jpg

Example of Spinal Cord Release Patient is a 62 y. o. female with history

Example of Spinal Cord Release Patient is a 62 y. o. female with history of progressive myelopathy and evidence of significant C 2 -C 3 stenosis with cord compression and cord signal changes Pre-Operative Diagnosis: C 2 -3 stenosis. Procedure: C 2 -3 laminectomy. Operative report description: “Drilled through the bone at the lateral border of the lamina bilaterally from C 2 to C 3, taking care not to widen the laminectomy so far as to disturb the facets or the stability of the spine at that level. The spinous processes and lamina were then removed en bloc using an upward motion (away from the spinal canal). After adequate central decompression was achieved” M 48. 02 Spinal stenosis – cervical region G 95. 20 Cord compression 00 NW 0 ZZ Release of the cervical spinal cord, open approach.

Multiple Decompressive Cervical Laminectomies ICD-10 -CM/PCS Coding Clinic, Second Quarter ICD-10 2015 Pages: 21

Multiple Decompressive Cervical Laminectomies ICD-10 -CM/PCS Coding Clinic, Second Quarter ICD-10 2015 Pages: 21 -22 Effective with discharges: July 6, 2015 Question: The patient is an 83 -year-old male who presented with cervical myelopathy. He elected to proceed with decompressive cervical laminectomy to release the spinal cord. The surgeon performed an open total decompressive laminectomy of C 3, C 4, C 5 and partial decompression of C 6. Would it be appropriate to count each vertebra separately, (i. e. , C 3, C 4, C 5, and C 6) and report four ICD-10 -PCS codes? Or, is it appropriate to count each vertebral level decompressed, such as C 3 -4, C 45, and C 5 - C 6? ICD-10 - PCS Guideline B 3. 2 states, "During the same operative episode, multiple procedures are coded if: The same root operation is repeated at different body sites that are included in the same body part value. " Answer: The laminectomy procedure to release the spinal cord is coded only once because the cervical spinal cord is classified as a single body part. By convention, the vertebral level (C 3, C 4, and so on) is used to identify a specific area along the spinal cord, but each designation is not considered a separate and distinct body part anatomically. The current version of the ICD-10 -PCS guideline B 3. 2 b states, "During the same operative episode, multiple procedures are coded if: The same root operation is repeated at different body parts that are included in the same body part value. " The guideline uses two separate and distinct muscles in the upper leg as an example of the correct application of the guideline. The vertebral level designations of the cervical spinal cord do not constitute separate and distinct body parts anatomically, therefore the multiple procedures guideline B 3. 2 b does not apply. Assign the following ICD-10 -PCS code: 00 NW 0 ZZ Release cervical spinal cord, open approach Although the ICD-10 -PCS “Index entry "Laminectomy, " instructs to see Excision, the objective of a decompressive laminectomy is to release pressure and free up the spinal nerve root. Therefore the appropriate root operation is "Release. "

Compression spinal meninges Compression of spinal meninges (thecal sac) Laminectomy, laminotomy facetectomy, and/or foraminotomy

Compression spinal meninges Compression of spinal meninges (thecal sac) Laminectomy, laminotomy facetectomy, and/or foraminotomy For the “Release” of spinal meninges due to adhesions or tumors https: //s-media-cache-ak 0. pinimg. com/originals/d 5/e 6/44/d 5 e 644 c 747 e 44 d 2 c 6086028 b 462 ff 908. png

Decompression Spinal Meninges are three membranes that envelop the brain and spinal cord. The

Decompression Spinal Meninges are three membranes that envelop the brain and spinal cord. The meninges are the dura mater, the arachnoid mater, and the pia mater. Release of spinal (dura) meninges for adhesions or tumors

3 M Coding Path

3 M Coding Path

Example of Spinal Meninges Release Preoperative Diagnosis: recurrent lumbar stenosis L 2 -3 with

Example of Spinal Meninges Release Preoperative Diagnosis: recurrent lumbar stenosis L 2 -3 with neurogenic claudication. Previous L 3 - L 4 laminectomy. Postoperative diagnosis: Epidural fibrosis (adhesions) Procedure description: A complete L 2 laminectomy was then performed. The dura was adherent and was dissected free. Correct codes: Spinal stenosis L 2 -L 3 M 48. 06 Release of the spinal nerves 01 NB 0 ZZ Release of the spinal meninges 00 NT 0 ZZ **ICD-10 -CM does not have a code for neurogenic claudication

Example of Spinal Meninges Tumor Pre-operative Diagnosis: L 3 intradural extramedullary mass Post-operative Diagnosis:

Example of Spinal Meninges Tumor Pre-operative Diagnosis: L 3 intradural extramedullary mass Post-operative Diagnosis: Schwannona Operation Performed: L 3 laminectomy, resection of intradural, extramedullary mass Op note description: L 3 laminectomy and Minimal facetectomy was also performed to get good bilateral access to thecal sac. Incision of the dura with the tumor was found deep to the nerve roots and was elevated out of thecal sac with removal from the nerve roots. The correct codes are: D 32. 1 Benign neoplasm of the spinal meninges 00 B 20 ZZ Excision of dura mater, open approach The laminectomy is not coded as it is the approach to the procedure

Example of Synovial Cyst of Spine

Example of Synovial Cyst of Spine

Artificial Discs Herniated or damaged discs are replaced with artificial disc devices in either

Artificial Discs Herniated or damaged discs are replaced with artificial disc devices in either the cervical or lumbar spine. Artificial disc replacement was developed as an alternative to spinal fusion surgery and is designed to reduce or eliminate a patient’s pain level while still maintaining motion throughout the spine.

Additional Procedure Performed During Spinal Surgeries Procedures Coded: Nerve monitoring Computer and/or robotic assisted

Additional Procedure Performed During Spinal Surgeries Procedures Coded: Nerve monitoring Computer and/or robotic assisted surgery Aspiration of bone marrow for graft Excision of bone for bone graft from another site Discectomy Decompression if done at a different level than the fusion Procedures Not Coded: Microscopy and Fluoroscopy not coded

Complications Inadvertent dural tear G 97. 41 (incidental durotomy, inadvertant entrance into dura) Symptoms

Complications Inadvertent dural tear G 97. 41 (incidental durotomy, inadvertant entrance into dura) Symptoms include: postural headache, posterior neck pain or stiffness, nausea, vomiting, photophobia, diplopia, blurred vision, tinnitus, or vertigo. Incidental tear of the dural sac and cerebrospinal fluid leak is the most common complication during lumbar spinal surgery. The incidence of dural tear differs depending on the procedure but is much more common in revision procedures, usually because of adhesions in the epidural space and dural scarring and fibrosis. Most dural tears are recognized during the operative procedure and primary repair is performed. Clinical Documentation Concepts If the tear is due to a procedure performed during the current admission report 'Accidental puncture or laceration of dura during a procedure' (G 97. 41). Always list the dural tear as a secondary diagnosis when it is documented by the physician, even if documented as "incidental". Dural tears are considered clinically significant because of a risk for cerebrospinal fluid leak.

Dural Tear Due to Previous Procedure ICD-10 -CM/PCS Coding Clinic, Fourth Quarter ICD-10 2014

Dural Tear Due to Previous Procedure ICD-10 -CM/PCS Coding Clinic, Fourth Quarter ICD-10 2014 Page: 24 Effective with discharges: December 31, 2014 Question: A patient who was diagnosed with spinal stenosis underwent L 2 -L 3 posterolateral fusion, and repair of midline durotomy. In the body of the report, the provider documented that the durotomy was probably created from previous epidural injections. Is it appropriate to assign code G 97. 41, Accidental puncture or laceration of dura during a procedure, for the durotomy due to previous epidural injections? Answer: Assign code G 96. 11, Dural tear, for the durotomy secondary to previous epidural injections. In ICD- 10 CM, "Non-traumatic dural tear" is specifically indexed to code G 96. 11. Also, assign code Y 84. 8, Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure. In this case, the tear happened before the procedure, so it is not related to the procedure. Code G 97. 41 would have been assigned if the durotomy had occurred during the current operation.

Lipomyelomeningiocele and Tethered Cord Lipomyelomeningocele: A rare congenital condition where a fatty mass is

Lipomyelomeningiocele and Tethered Cord Lipomyelomeningocele: A rare congenital condition where a fatty mass is attached to the spinal cord and protrudes through a defect in the spinal cord. Tethered spinal cord syndrome is a neurological disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal column. Attachments may occur congenitally at the base of the spinal cord (conus medullaris) or they may develop near the site of an injury to the spinal cord.

Repair of Lipomyelomeningocele and Tethered Cord Question: A 5 -week-old baby, who is diagnosed

Repair of Lipomyelomeningocele and Tethered Cord Question: A 5 -week-old baby, who is diagnosed with lipomyelomeningocele and tethered cord, presents for untethering of the cord, excision of the lipoma, which involved the lumbosacral portion of the spinal cord, and microdissection of the spinal cord. At surgery, the area above the lipoma was dissected, and a S 1 laminoplasty was performed. After freeing up the dural edges, the lipoma was dissected. Dural patch graft was sewn in using Durepair® to cover the wide opening at the site in which the lipoma was removed. What are the appropriate ICD-10 -PCS codes for this procedure? Answer: 00 NY 0 ZZ Release lumbar spinal cord, open approach (for the release of tethered cord) 0 QQ 10 ZZ Repair sacrum, open approach (for the S 1 laminoplasty) 00 BY 0 ZZ Excision of lumbar spinal cord, open approach (for the excision of the lipoma) 00 UT 0 KZ Supplement spinal meninges with nonautologous tissue substitute, open approach (for the dural patch graft with Durepair®) Code update 4 th Q 2015, P 39 The Coding Clinic advice is accurate. The body part value "Spinal Meninges" was intentionally chosen. In the Central Nervous System, the body part value dura mater refers exclusively to the dura mater covering the brain. The body part value Spinal Meninges includes all meningeal layers covering the spinal cord. The exclusive use of the dura mater body part value to refer to the brain produces clearer coded data, because it is more important to know whether the procedure was performed on the brain or the spinal cord than it is to know that a procedure was performed on the dura mater meningeal layer. The body part key has been revised to reflect this.

st 1 Quarter 2017 Coding Clinic A staged anterior thoracolumbar fusion of T 12

st 1 Quarter 2017 Coding Clinic A staged anterior thoracolumbar fusion of T 12 -S 1 is followed by iliac fixation and posterior instrumented T 10 S 1 fusion with VIPER® 2 System the next day. At the second surgery bone graft was placed for posterior-lateral fusion and titanium rods were connected via pedicle screws from T 10 -S 1 and anchored or fixated with screws to the iliac crest. In addition to coding the posterior-lateral fusion, fixation to the right and left iliac wings (0 QH) should be assigned to report fixation that is beyond the fused vertebral levels (sacrum). The sacro-iliac joint is not part of the vertebral joints fused.

VERTEBROPLASTY This procedure is performed when there is a pathological fracture of a vertebrae

VERTEBROPLASTY This procedure is performed when there is a pathological fracture of a vertebrae due to Osteoporosis or cancer or when they are treating a traumatic fracture. This is done for non-displaced fractures. The correct root operation is supplement since the bone is being supplemented with bone cement.

Coding Clinic 2 Q 2014

Coding Clinic 2 Q 2014

OP Report Exercises Fusions Release

OP Report Exercises Fusions Release

References: BARTLEY. COM GREAT BOOKS ONLINE HENRY GRAY (1825 -1861). ANATOMY OF THE HUMAN

References: BARTLEY. COM GREAT BOOKS ONLINE HENRY GRAY (1825 -1861). ANATOMY OF THE HUMAN BODY. 1918 HTTP: //WWW. BARTLEBY. COM/107/PAGES ICD-10 -CM OFFICIAL GUIDELINES FOR CODING AND REPORTING FY 2017 (OCTOBER 1, 2016 - SEPTEMBER 30, 2017) HTTPS: //WWW. CMS. GOV/MEDICARE/CODING/ICD 10/DOWNLOADS/2017 -ICD-10 -CM-GUIDELINES. PDF JATA CDMP GUIDE TEACH ME ANATOMY. INFO HTTP: //TEACHMEANATOMY. INFO/BACK/BONES/VERTEBRAL-COLUMN/ THE FREE DICTIONARY BY FARLEX HTTP: //MEDICAL-DICTIONARY. THEFREEDICTIONARY. COM 3 M CODING AND REIMBURSEMENT SYSTEM WIKIPEDIA. ORG HTTPS: //EN. WIKIPEDIA. ORG/WIKI/VERTEBRAL_COLUMN

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