Spinal Procedures Reported in Addition to the Fusion

Decompression of the spinal cord/nerve

Coding decompression procedures separately will depend on the documentation by the physician of what body part is being decompressed/released and if there is a distinct surgical objective. If the laminectomy (many times called a decompression) is only performed to reach the site of the planned spinal fusion, then no additional code would be reported. This is true even if the decompression is at the same level as the fusion. The operative note should indicate what is being released/decompressed (spinal cord/nerve). Look for terms such as stenosis, compression, decompression, myelopathy, and radiculopathy to name a few. These are terms that may be hints that a decompression was needed and completed to address a specific diagnosis.

The root operation used to report the decompression is “release.”  The definition of release in ICD-10-PCS is “freeing a body part from an abnormal physical constraint by cutting or by use of force.” This means that the restraining tissue may be removed but none of the body part being compressed is taken out. In the case of spinal cord/nerve root compression, the body part that is being freed is the spinal cord or the nerve roots. Whatever is compressing these can be removed to release the compression. The release of spinal cord is only coded once since the spinal cord is classified as a single body part (per spinal level such as cervical, thoracic, lumbar, and lumbosacral). The specific ICD-10-PCS code will depend on the level of the spine the procedure is being performed on.

Discectomy—Excision or Resection

This is performed to remove herniated intervertebral disk in the spine. When a disk is herniated, it may cause pain and numbness due to the material compressing the spinal nerves and/or spinal cord. Most often, the surgeon will only remove a portion of the disk material that is causing the compression or “pinching the nerve.” This would be coded with the root operation “excision.” The definition of excision in ICD-10-PCS is “cutting out or off, without replacement, a portion of a body part.” If the surgeon does remove the entire disk, this is coded with the root operation “resection.” The definition of resection in ICD-10-PCS is “cutting out or off, without replacement, all of a body part.” The discectomy is most often coded in addition to the spinal fusion as there is almost always a separate and distinct diagnosis that requires the discectomy to be performed. The operative note should clearly state what the discectomy is being performed for, and if there is partial or total removal of the disc.

Other Less Common Procedures Missed

• Removal of internal fixation devices
• Computer assisted procedure—Stealth Navigation System
• Monitoring of peripheral nervous electrical activity, intraoperatively
• Removal of previous interbody fusion device

There are so many references available on coding of spinal fusions and associated procedures listed below, and this is not even all of them that are available. If in doubt, take time to research these. There are also action plans available that are an excellent reference for coding of spinal fusions.

Another great reference is our eBook on Spinal Fusion Coding. Download here. 

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

References
https://www.hopkinsmedicine.org/health/conditions-and-disease/spinal-cord compression
https://my.clevelandclinic.org/health/articles/10874-spinal-decompression-surgery
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2015 Pages: 16-17
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2019 Pages: 28-30
ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2019 Page: 30
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2017 Pages: 23-24
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2015 Pages: 21-22, 34
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2016 Pages: 16-17
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2017 Pages: 76-77
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2014 Pages: 6-8
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2013 Pages: 29-30
ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2018 Page: 30

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 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.