Getting to the Backbone of Spinal Coding in ICD-10-PCS

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1 Getting to the Backbone of Spinal Coding in ICD-10-PCS Sponsored by 1915 N. Fine Ave #104 Fresno CA Phone: (559) Fax: (559) Program Handouts Tuesday, June 9, 2015 Track One 2:10 pm 3:10 pm 2015 State Convention and Exhibit Speaker Kristi Pollard, RHIT, CCS, CPC, CIRCC AHIMA-Approved ICD-10 Trainer Copyright California Health Information Association, AHIMA Affiliate

2 California Health Information Association California Health Information Association Getting to the Backbone of Spinal Coding in ICD 10 PCS June 9, 2015 Kristi Pollard, RHIT, CCS, CPC, CIRCC Senior Coding Consultant, AHIMA Approved ICD 10 CM/PCS Trainer Haugen Consulting Group Disclaimer This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner. The author is not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding. Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation. Copyright California Health Information Association, AHIMA affiliate 1

3 Goals/Objectives or Agenda Review coding pertinent spinal anatomy Review coding guidelines for spinal fusions Determine root operations and devices for spinal procedures Abstract applicable information from an operative report and apply codes Have fun! Spinal Primer I ve got your back! Copyright California Health Information Association, AHIMA affiliate 2

4 Vertebral Segment Anatomy in 2D The vertebral ring Vertebral body anterior Spinous process posterior Transverse processes (2) sides Lamina (2) connect spinous process to transverse processes Pedicles (2) connect transverse processes to vertebral body Intravertebral foramen hole in middle of segment for spinal cord Intervertebral Disc, Spinal Cord, and Nerve Roots Copyright California Health Information Association, AHIMA affiliate 3

5 Vertebral Segment Anatomy in 5D! Facets Projections that articulate with vertebrae tb above and below AKA articular process Per PCS Body Part Key, code to Joint (Upper/Lower) Look for spinal region in Body Part Key (e.g., Cervical facet joint) Include joint structures Cartilage Synovial fluid Putting the Pieces Together Neuroforamen Space created between segments Allows for spinal nerves to exit spinal canal Copyright California Health Information Association, AHIMA affiliate 4

6 Segments (Bones) vs. Spaces (Joints) Root Operation = Fusion Procedure intent To render an intervertebral joint immobile Root operation Fusion Body Systems Upper Joints Lower Joints UGH How do I code an anterior fusion from an anterior approach? Copyright California Health Information Association, AHIMA affiliate 5

7 Body Part(s) for Spinal Fusion B3.10a 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. Spinal Fusion Upper Joints (0RG) Occipital cervical Joint (0) Cervical Vertebral Joint (1) CervicalVertebral Joints, 2 or more (2) Cervicothoracic Vertebral Joint (4) Thoracic Vertebral Joint (6) Thoracic Vertebral Joints, 2 to 7 (7) Thoracic Vertebral Joints, 8 or more (8) Thoracolumbar Vertebral Joint (A) Copyright California Health Information Association, AHIMA affiliate 6

8 Spinal Fusion Lower Joints (0SG) Lumbar Vertebral Joint (0) Lumbar Vertebral Joints, 2 or more (1) Lumbosacral Joint (3) Sacrococcygeal Joint (5) CoccygealJoint (6) Sacroiliac Joint, Right (7) Sacroiliac Joint, Left (8) Devices for Spinal Fusion Blah! Blah! Blah! B3.10c Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows: 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 If bone graft is the only device used to render the joint immobile, the procedure is coded with the device value 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 the device value Autologous Tissue Substitute Copyright California Health Information Association, AHIMA affiliate 7

9 Spinal Fusion Device Hierarchy Guideline B3.10c made simple! Interbody Fusion Devices Device placed between vertebral bodies AKA cage Titanium Polyetheretherketone (PEEK) (plastic) Always placed in anterior column Cage = interbody fusion device = anterior column Copyright California Health Information Association, AHIMA affiliate 8

10 Remember Cages are interbody fusion devices that fuse the anterior column Interbody Fusion Copyright California Health Information Association, AHIMA affiliate 9

11 Bone Graft Autologous from patient Nonautologous from donor (e.g., cadaver, bone bank) Code harvesting of bone graft separately if taken from a separate operative site (e.g., ilium) Multiple Codes for Spinal Fusion B3.10b If multiple vertebral joints arefused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier. Copyright California Health Information Association, AHIMA affiliate 10

12 Qualifier Example Fusion Qualifiers Anterior Approach, Anterior Column (0) Look for supine positioning Tedious dissection, fusion of front of back Posterior Approach, Posterior Column (1) Look for prone positioning Easy access, fusion of back of back Posterior Approach, Anterior Column (J) Look for prone positioning Easy access, sneak around technique to fuse front of back Copyright California Health Information Association, AHIMA affiliate 11

13 Spinal Fusion Anterior Column Fusion 360 Fusion Anterior and posterior column fusion Posterior Column Fusion Lumbar Interbody Fusion (Anterior Column) Procedure Operative Approach Approach Anterior lumbar interbody fusion (ALIF) Incision made in front of the spine through a small incision (minilaparotomy) or through a laparoscopy Anterior Posterior lumbar interbody Incision made through a midline Posterior fusion (PLIF) incision in the back Extreme lateral interbody Incision made in the patient s side Anterior fusion (XLIF) Direct lateral linterbody fusion Incision ii made in patient s side Anterior (DLIF) Transforaminal lumbar Incision made through a posterior Posterior interbody fusion (TLIF) approach Copyright California Health Information Association, AHIMA affiliate 12

14 Pedicle Screw Fixation Adjunct to Fusion Placement of pedicle screws connected by rigid rods Coding Clinic, Third Quarter 2014, page 30 All fixation is included in fusion root operation Do code insertion of pedicle screws with spinal fusion Let s Code it! Case 1 Copyright California Health Information Association, AHIMA affiliate 13

15 Operative Report page 1 PREOPERATIVE DIAGNOSIS: Lumbar spinal stenosis, spondylolisthesis, and scoliosis L3 S1. POSTOPERATIVE DIAGNOSIS: Lumbar spinal stenosis, spondylolisthesis, and scoliosis L3 S1. OPERATION PERFORMED: L3 S1 lumbar laminectomy, decompression of cauda equina, posterior spinal fusion, segmental instrumentation, and local bone grafting. SUMMARY OF OPERATION: After adequate general anesthesia was obtained, the patient was positioned prone on the operating table. We prepped and draped the back in the usual sterile fashion. Operative Report page 2 A midline incision was made. The spine was exposed in its lower segments. The L4 5 space was identified by palpation. A marker was placed, and a radiograph was obtained which confirmed our location. We carried the exposure up to the top of L3 and down to the sacrum. We carried the exposure out to the transverse processes of L3, L4, L5, and the sacral ala. The facet joint capsules were stripped at L3 4, L4 5, and L5 S1. The osteophytes were removed as well. We stripped the interspinous ligaments at L3, L4, and L5. Next, we used a half inch osteotome, Leksell rongeurs, and Kerrison rongeurs to open our laminectomy. We removed the entire lamina of L3, L4, and L5. We found very severe stenosis, especially on the right side at L3 4 and L4 5. Copyright California Health Information Association, AHIMA affiliate 14

16 Operative Report page 3 We thoroughly irrigated out the entire incision with sterile saline. Next, we used the Synthes Universal Spine System and placed 7 x 45 mm screws at L3, L4, L5, and sacrum. On the left side, I was able to use the standard landmarks of the base of the transverse process and junction with the superior facet. On the right side, the anatomy was significantly distorted because of the degenerative scoliosis. I was able to place screws at L3, L4, and S1 using the standard landmarks. At L5, I had to use radiographic guidance in order to localize the pedicle. After the screws were placed, AP and lateral C arm images were obtained which showed an acceptable position of all screws. Finally, we cut and contoured 2 pieces of rod from the Universal Spine System andattachedattached these to the screws oneach side. Allattachments were torque tightened appropriately. We decorticated the transverse processes and sacral ala. Our bone graft, which was saved from the decompression, was morselized using the bone mill, and it was placed posterolaterally from L3 down to the sacrum on each side. Operative Report page 4 A final inspection of the canal was made. A medium Hemovac drain was left deep to the fascia. The fascia was closed with a 0 Vicryl suture. The subcu was closed with 2 0 Vicryl, and the skin was closed with 3 0 subcuticular. Sponge and needle counts were correct. Blood loss was about 400 ml. The patient went to Recovery in good condition. Copyright California Health Information Association, AHIMA affiliate 15

17 Case 1 Codes 0SG1071, fusion 2 4 lumbar joint with autologous tissue substitute, posterior approach posterior column, open 0SG3071, fusion lumbosacral joint with autologous tissue substitute, posterior approach posterior column, open Let s Code it! Case 2 Copyright California Health Information Association, AHIMA affiliate 16

18 Operative Report page 1 PREOPERATIVE DIAGNOSIS: L4 5 spinal stenosis and disc degeneration. POSTOPERATIVE DIAGNOSIS: L4 5 spinal stenosis and disc degeneration. PROCEDURES: 1. Lumbar posterolateral arthrodesis, L Posterior segmental spinal instrumentation Medtronic Solera at L4 5 (6.25 x 45 mm screws x4, contoured rods x2). 3. Posterior lumbar interbody fusion, L Application of Medtronic 10 x 26 mm interbody fusion cage, L Local bone graft plus corticocancellous allograft. 6. Intraoperative neuromonitoring. Operative Report page 2 DESCRIPTION OF PROCEDURE: The patient was placed prone on the Jackson table 4 poster frame. The skin was prepped and draped, and a 10 blade was used to make a longitudinal midline incision centered over the L4 5 interspace and carried through the skin, subcutaneous tissue, and the dorsolumbar fascia. The posterior bony elements and transverse processes of L4 and L5 were exposed bilaterally and cerebellar retractors x2 placed. The image intensifier was used to verify the correct level. Using a 1/2 inch osteotome and Leksell and Kerrison rongeurs, the inferior part of the L4 lamina and superior part of the L5 lamina were removed. Partial facetectomies were performed bilaterally to decompress the thecal sac and lateral nerve roots. There appeared to be remnants of a synovial facet joint cyst on the left side at L4 5 which was adherent to the thecal sac and nerve root. It was carefully mobilized with a Penfield 4 elevator and removed with the pituitary rongeur. Dorsally, a 2 mm dural tear was noted and repaired with 5 0 Prolene. Copyright California Health Information Association, AHIMA affiliate 17

19 Operative Report page 3 Attention was turned to the interbody fusion at L4 5. The L5 nerve was mobilized and retracted towards midline using a Penfield 4 elevator, followed by bayoneted nerve root retractor. Under distraction afforded by the laminar spreader, an annulotomy was made at L4 5. Straight up and down biting pituitary rongeurs, Scoville curette, and nerve hook were used to mobilize and completely remove the disc and curette the facing endplates. Trial spacers were placed. A 10 mm x 26 mm PEEK cage was packed with local bone graft plus corticocancellous allograft and impacted into the L4 5 disc space after corticocancellous allograft andlocal bone graft was placed into the interspace. The cage appeared in satisfactory position. Operative Report page 4 After irrigation, attention was turned to the internal fixation and lateral arthrodesis. The pedicles of L4 and L5 were entered with the bur and the starting awl utilizing landmarks including palpation of the medial wall of the pedicles, transverse process, pars interarticularis, and facet joints; 6.25 mm screws were placed into the pedicles of L4 and L5 bilaterally after placement of local bone graft plus corticocancellous allograft to promote lateral arthrodesis. The screws were connected with contoured rods and secured with the caps and torque driver after final images were taken. The construct appeared stable. After irrigation and inspection of the canal, the fascia was approximated over a medium Hemovac drain with 0 Vicryl, the subcutaneous tissue with 2 0 Vicryl, and the skin with running subcuticular 3 0 Monocryl followed by Dermabond. Copyright California Health Information Association, AHIMA affiliate 18

20 Case 2 Codes 0SG00AJ, Fusion lumbar vertebral joint with interbody fusion device, posterior approach anterior column, open 0SG0071, fusion lumbar vertebral joint with autologous tissue substitute, posterior approach posterior column, open 0ST20ZZ, resection of lumbar vertebral disc, open approach 00Q20ZZ, repair dura mater, open approach Procedures That Code to the Root Operation Insertion Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part Copyright California Health Information Association, AHIMA affiliate 19

21 Other Procedures on Vertebral Joints Interspinous Process Devices (IPD) Also known as Interspinous process decompression device Interspinous process distraction device X Stop Spacer Device: Spinal Stabilization Device, Interspinous Process (B) Copyright California Health Information Association, AHIMA affiliate 20

22 Posterior Dynamic Spinal Stabilization Indications Symptomatic spondylolisthesis Degenerative disc disease Lumbar spinal stenosis Components Screws and rods Screws, rods, and spacers Screws and flexible rods Screws and rods with movable parts Flexible screws and flexible rods Screws and inflatable rods Device: Spinal Stabilization Device, Pedicle Based (C) Facet Replacement Treatment of facet pain or spinal stenosis Many devices still undergoing clinical trials Caution! Facet replacement does not code to root operation Replacement! It is coded to Insertion Device: Spinal Stabilization Device, Facet Replacement (D) TOPS Total Posteriorelement System TFAS Total Facet Arthroplasty System Copyright California Health Information Association, AHIMA affiliate 21

23 Other Spinal Procedures More tools to help you succeed! Discectomy Partial = Excision Total = Resection Coded when performed prior to fusion Coding Clinic, Second Quarter 2014, page 7 Copyright California Health Information Association, AHIMA affiliate 22

24 Disc Replacement Includes removal of disc and placement of springlike device to take its place Allows for movement Does not fuse joint Disc Replacement Building the Code Section = Medical and Surgical (0) Body System Upper Joints (R) Root Operation = Replacement (R) Body Parts Cervical Vertebral Disc (3) Cervicothoracic Vertebral Disc (5) Thoracic Vertebral Disc (9) Thoracolumbar Vertebral Disc (B) Section = Medical and Surgical (0) Body Systems Lower Joints (S) Root Operation = Replacement (R) Body Parts Lumbar Vertebral Disc (2) Lumbosacral Disc (4) Copyright California Health Information Association, AHIMA affiliate 23

25 Decompression Procedures Laminotomy/ Foraminotomy Root Operation = Release Body Part = nerve root or spinal cord Laminectomy/ Hemilaminectomy Root Operation = Excision Body Part = upper or lower bones Do not code when performed as approach to another procedure (e.g., fusion) Vertebroplasty Root Operation = Supplement Body System = Upper or Lower Bones Device = Synthetic Substitute (PMMA cement) Coding Clinic, Second Quarter 2014, page 12: PMMA cement is a device per the Device Key in PCS Copyright California Health Information Association, AHIMA affiliate 24

26 Kyphoplasty Intent: Reposition vertebra and stabilize with PMMA Two root operations: Reposition (no device) Supplement (Synthetic Substitute) Summary Spinal Fusions Identify joint(s) fused Spaces, notsegments Look for transitional joints (e.g., L5 S1) Identify device and apply hierarchy guideline Identify approach (anterior vs. posterior) Identify column fused (anterior vs. posterior or 360 ) Other procedures Code decompression procedures only when not the approach to another procedure PMMA cement is a device! Copyright California Health Information Association, AHIMA affiliate 25

27 Questions? Bibliography 2015 ICD 10 PCS Code Set and Guidelines: ICD 10 PCS and GEMs.html Coding Clinic for ICD 10 CM/PCS, American Hospital Association, Fourth Quarter 2012 First Quarter 2015 Posterior Dynamic Stabilization Systems: surgery/posterior dynamic stabilizationsystems Discectomy: pain/discectomy or microdiscectomy / / for a herniated disc Laminectomy Copyright California Health Information Association, AHIMA affiliate 26

28 Bibliography Foraminotomy: Spinal Fusion: health.com/treatment/spinal fusion/interbodycages spine fusion Vertebroplasty: org/healthlibrary/test procedures/orthopa edic/vertebroplasty_135,37/ Kyphoplasty: Copyright California Health Information Association, AHIMA affiliate 27

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