Spinal Fusion Coding: Was A Decompression Done During Spinal Fusion?

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.

Coding Examples

To view coding examples, purchase our Spinal Fusion Coding eBook.

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

References
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
mayfieldclinic.com/pe-decompression.htm

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.

Leave a Comment

    Category

    Related blogs from Medical Coding Tips

    ICD-10-CM Coding for Malposition/Malpresentation o...

    Fetal positioning within the uterus is not of...

    Mar 26, 2024

    Pacemaker/AICD Status vs. Management ICD-10-CM Cod...

    ICD-10-CM Code Z95.0 and Z45.018 ICD-10-CM co...

    Cerebral Edema as a Clinically Significant Diagnos...

    A common misconception among coders is that c...

    Adding M.E.A.T. To Documentation Supports HCC Assi...

    Medicare Advantage Plans (Medicare part C) us...