Spinal procedure coding can be daunting for coders. The spine itself can be quite complicated anatomically and the procedures done to address spinal conditions can be even more complicated! HIA has developed an educational Action Plan to address one of these areas, spinal decompression coding. Below are a few excerpts from that Action Plan.
What is Spinal Compression?
Certain injuries and disorders may put pressure on the spinal cord itself or of spinal nerve roots which arise from the spinal cord and pass through spaces between the vertebrae. These conditions that cause compression can include:
- Thickened ligaments
- Bone Spurs
- Herniated intervertebral disc
As stated, compression can affect the spinal cord, and/or the spinal nerve roots. Sometimes it is difficult for coders to discern which. The operative report should reflect if the spinal cord, spinal nerve roots or both are compressed. The surgeon my not come out and state this directly however. The coder can look for other terms to help them ascertain what area is being decompressed. One such term is “thecal sac” or “dural sac.” This is the outer covering of the spinal cord and will let coders know to use that body part for the area that is compressed (cervical spinal cord, thoracic spinal cord or lumbar spinal cord.) The surgeon may state for example that he/she decompressed the lumbar thecal sac. This would mean the coder would code release of lumbar spinal cord in the Central Nervous System Body System.
Nerve roots come off the end of the cord (cauda equina) and exit the spine. This is a frequent location of nerve compression. This would signal that the coder use the body part for the level of spinal nerve in the Peripheral Nervous System Body System. (i.e., cervical nerve, thoracic nerve, lumbar nerve, sacral nerve)
There are differing procedures that can accomplish decompression of the spinal cord or spinal nerve roots. These include laminotomy(removal of small portion of lamina)/laminectomy(removal of entire bony lamina); foraminotomy/foraminectomy to remove bone around the neural foramen; discectomy to remove a portion of bulging or herniated or degenerative disc; osteophyte (bony growth or bone spurs) removal; corpectomy to remove all or a part of the body of a vertebra and laminoplasty which is the expansion of the spinal canal by cutting the lamina to release the spinal cord.
When a decompressive surgery is performed to relieve pressure on a body part, such as the nerve root or spinal cord, the appropriate root operation will be Release rather than the root operations Excision or Resection.
It is important to consider the objective of the procedure when choosing the root operation. There may be situations where there are two separate distinct objectives in the same procedure. For example, if the patient has a herniated disc and spinal stenosis, both causing pressure to be placed on the spinal nerve, the surgeon may remove the disc to treat the herniation, and a laminectomy to release pressure on the nerve from stenosis. In that scenario, it would be appropriate to code Excision or Resection for the removal of the herniated disc, and Release for decompression of the nerve. See Coding Clinic, Second Quarter 2016: Page 16.
Laminectomies may also be done as an approach. The root operation Release is coded separately when decompression is documented, and there is a distinct surgical objective, not just incidental removal of the lamina to reach the site of the procedure, which is not coded separately.
In summary, the takeaways in coding decompression are:
- Determine what body area that is being decompressed, spinal cord, spinal nerve root or both. Be guided by the anatomical terms used above.
- Determine the vertebral level in which the decompression is being done, i.e., cervical, thoracic, lumbar, sacral.
- Read and be guided by the method being used to decompress the area, remember that various procedures can decompress the spinal cord or spinal nerve roots, but the objective is to release the compression and the root operation assigned is “release.”
- Note the approach for the decompression or release of the spinal cord or spinal nerve roots, i.e., open, percutaneous endoscopic, etc.
- Review Official Coding Guidelines B3.13 and B3.14 as well as all pertinent Coding Clinics.
- Review operative note to be sure that no other codable procedures with separate objective are being done at the same time as the decompression.
AHA Coding Clinic
For the past 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.
The information contained in this post 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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