ICD-10-PCS Documentation and Coding for Spinal Procedures October 22, 2015

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1 Questions and Answers 1. We have a question regarding a spinal surgical procedure. The diagnosis was bilateral lateral recess stenosis and central stenosis from L2-L5. The procedure was an open lumbar laminectomy and bilateral foraminotomy of L2-L5. In the operative report, besides the obvious decompression of the spinal cord, there is the following documentation: There was facet joint hypertrophy and ligamentous hypertrophy out laterally and the lateral recesses of both sides. These were carefully removed, first on the patient's left side, and then on her right side, from rostral to caudal direction. Do we code both 00NY0ZZ for release of the spinal cord, open approach and 01NB0ZZ for decompression of the release of lumbar nerve, open approach? Or is it just the 00NY0ZZ? The details described do seem to imply a diagnosis of Lumbar nerve compression, but a diagnosis does not seem to be included/available. I would use the details of the bilateral foraminotomy to query for the indication of the procedure. If the procedure was for the decompression of the bilateral spinal nerves then I would code both the 01NB0ZZ and the 00NY0ZZ. 2. For approaches you said 'external would be for minor procedures like w a puncture through the skin.' Wouldn't this be considered percutaneous? Approach Definitions: Percutaneous: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure External: Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane Examples of spine Procedure using external approach- Removal of internal fixator from lumbar vertebrae External approach- (a small incision or puncture may be necessary to assist in External removal of a fixation device. External includes skin and mucous membrane). The operative report details will always be the best source to determine the code. If review of information implies something is missing or something more invasive was performed then the MD would need to be queried for clarification of external, percutaneous or open procedure) Example of an External Approach to the removal of internal fixation device: Code 0QP0X4Z Book Section = 0 Med surg Body system = Q lower bones Root Operation = P removal Body Part= 0 Lumbar Vertebrae Approach = X External Device = 4 internal fixation device Qualifier = Z none 1

2 Open is used When Incision is made with cutting/scalpel thru layers of tissue to expose the targeted operative site Percutaneous is used when Tissue is punctured and instrumented thru the layers of tissue to reach the targeted operative site. External is used- When the targeted operative site is reached without passing thru deeper layers of tissue (skin and mucous membrane only) to reach the targeted operative site 3. Is a bone graft coded separately? Without a specific example not clear for a specific coding answer to be given. PCS guidelines instruct additional procedures are coded when a different body part, different root operation or different approach is used. An example of coding also the bone graft performed: a. Example open- Internal fixation of displaced L4 vertebrae body fx posterior/lateral using titanium screw and autologous graft for reinforcement and healing b. 0QU07Z - Supplement using Autologous tissue substitute c. 0QS004Z- Reposition Lumbar vertebrae using internal fixation device 4. Aren t screws and plates integral to procedure and not coded? For spinal Fusions yes the screws and plates are integral and not coded separately If the objective is not fusion and consists of another root operation using screws and plates the PCS table using the 6 th character device may be assigned (example: 6 th character internal fixation device meaning plates and screws) 5. Do we still not code corpectomies and diskectomies together in ICD-10-PCS? AHA Coding Clinic for ICD-10-CM and ICD-10 PCS, 2Q 2014, Volume 1, Number 2, Pages 6-8 refer to the coding clinic which gives two examples of the coding of diskectomy when performed with Fusion. Without the operative report it is a challenge to answer optimally but in the instance you describe corpectomy with disckectomy if it is the only procedures performed I would direct you to evaluate - The objective of the procedure which determines the coding- If the objective is to resect the entire vertebrae and the entire Disc with/without placement of device to same, then both would be coded If the objective is to excise a portion of the vertebrae to access the disc to perform a resection of the entire disc then just the resection of Disc would be coded 2

3 6. Our surgeon documents neurogenic claudication as an additional dx with stenosis. Is G95.19 an appropriate secondary dx? Yes G95.19 is the correct secondary code for neurogenic claudication. 7. Would a laminectomy for decompression of a nerve root at the same site of the fusion be coded too? Yes code both the decompression of the nerve and the Fusion of the Vertebral Joints. Refer to coding clinic examples for laminectomy procedures 8. When an auto graft alone is performed w/out the insertion of a cage, is the auto graft px considered a device? Based on your question for the procedure performed the answer is yes. a. Example open- fusion of L4 L5 vertebrae body anterior column, using posterior approach using autologous graft for fusion b. 0SG007J- Fusion Lower Joints- Lumbar vertebral joint- open- autologous tissue substitute- Posterior approach anterior column 9. Can you give examples of spinal procedures using the approaches percutaneous endoscopic versus artificial opening endoscopic? An example is Percutaneous endoscopic Laminectomy None of the Spine nor Central/peripheral nervous system root operation/procedures use the approach characters 7 Via Natural or Artificial Opening, or 8 Via Natural or Artificial Opening Endoscopic 10. Would a diskectomy be coded when it is being removed so that interbody fusion device is being inserted? If the Operative report documents that the disc is excised or resected, the root operation for the diskectomy procedure would be coded in addition to the root operation of Fusion procedure code with 6th character selection of interbody fusion device. 11. How would a laminectomy for decompression of a nerve root at the same site of the fusion be coded? Code the Decompression of nerve root and the Fusion separately for the specific body part for spinal nerve root decompressed and the specific body part for the vertebral joints fused. 12. When is the next training for PCS and/or CM? This presentation was excellent. Thank you! 3

4 Contact your Elsevier representative, check the Elsevier web site. 13. Where can we find a list of the DRGs for ICD 10 and there definitions? Do we presume that all laminectomies will be coded with fusions? No presumptions to procedures should be made, code only the detailed procedures, if there is a question as to what the objective is for the procedure performed then the provider should be queried. Also follow your Code book guidelines, PCS guidelines, and any coding clinic advice on the subject, to be sure you are consistent with published guidance. 15. If a disc is removed between L1 and T12, is that considered upper or lower? The PCS table for Excision of Upper Joint includes the selection Thoraco-lumbar Disc 16. Is the disc between L1 and t12 considered upper or lower? The PCS table for Excision of Upper Joint includes the selection Thoraco-lumbar Disc 17. How do you code lumbar spinal stenosis with neurogenic claudication in ICD-10 CM? M48.06 Lumbar Spine Stenosis G95.19 neurogenic claudication 18. Why is a decompression coded with a fusion? Per the official PCS guidelines when multiple procedures are performed the number of codes is determined by the different objective(s), Different body part(s) and, or a different root operation of the procedures. A decompression is a release root operation for either spinal cord or spinal nerves, The fusion root operation is the permanent rendering of a Vertebral joint(s) immobile using various devices 19. L4 burst fracture. Physician performs L4 corpectomy to treat. Is this a decompression root operation? Read the operative report carefully to determine the objective of the procedure. A Corpectomy is typically the total resection of a vertebral body (L4) root operation = resection. However review the procedure note carefully as the term corpectomy is sometime used when only a portion of the Vertebral body is removed in this case the root operation would be excision 20. Is neurolysis same as release of the spinal nerve? 4

5 Neurolysis can be achieved by root operations destruction, release or division. To determine the root operation used, carefully review the details of the procedure for key terminology that describes the objective. Some nerves require permanently destroying a portion or all of the nerve to facilitate symptom improvement, Some nerves are merely entrapped and when released have relief of symptoms, and some nerves are cut/divided to relieve symptoms. 21. An excision of nerve sheath tumor, is what body part? PCS code book guidelines and tables direct the coder to use the nearest proximity body part/region when the specific description does not exist, and provides a resource in the appendix of the book for body/body region identification. Nerve sheath is the structure that surrounds the core of the nerve root, so the body part selections would be the specific nerve that the tumor is attached to. 22. In the kyphoplasty example why was biopsy not coded separately on the slide? You are correct in identifying that biopsy was an omission for the coded slide, It was included in the prior slide for the description of the objectives and root operations. It should be coded as it is a biopsy that is sent for pathology exam (diagnostic). 23. For fusions, if they fuse the anterior spine with an interbody fusion device, and then place rods and screws on the posterior spine with no other device, do you consider the rods and screws as integral to the anterior fusion? It sounds like you have a procedure that is an anterior fusion using posterior approach, The operative details should be reviewed to determine if the procedure performed for the IBFD placement at the same vertebral level, is also for the hardware placed on the posterior side. Review carefully for incisions described as anterior and posterior. For example: 0SG00AJ- Fusion lower joint, lumbar vertebral joint-open approach- IBFD- Posterior approach /anterior column. No additional device is coded 24. Is every procedure coded when multiple procedures are being done? For examples: fusion, nerve root decompression, diskectomy all at one time Per the official PCS guidelines when multiple procedures are performed the number of codes is determined by the different objective(s), Different body part(s) and, or a different root operation of the procedures. A decompression is a release root operation for either spinal cord or spinal nerves, The fusion is the permanently rendering a Vertebral joint(s) immobile using various devices, Disckectomy may be an excision or resection of a disc. 25. Do we code both the procedures for Spinal Fusion and decompression when done on the same disc level? Code the Decompression of nerve root/spinal cord and the Fusion separately for the specific spinal nerve root/spinal cord level decompressed and the specific vertebral joints fused. 5

6 26. If the fusion is done with only screws and morselized bone this would be an interbody fusion device? An interbody fusion device involves the removal of some or all of the disc, or some or all of a vertebra with an IBFD placed between two Vertebral joints. Review carefully the procedure to determine the objective, and the devices that are used. If your review determines that an IBFD was placed with morselized bone than code with the Device IBFD. Be careful to discern between fusion that is done to connect joints and fuse them from outside the vertebrae vs fusion involving the placement of a device between the vertebral joint space. 27. What is the procedure code for removal of a tumor from the epidural space? The code for Extirpation of tumor from epidural space 00C30ZZ 28. Is the bx done with the kyphoplasty coded separately? You are correct in identifying that omission for the coded slide; It was included in the prior slide for the description of the objectives and root operations. It should be coded as it is a biopsy that is sent for pathology exam. 29. Do you code the bone morphogenetic protein separately? Is there is a code for it? 3E0V3GB? The coding clinic says not to code it separately? The code is 3E0V0GB For Administration, Physiologic Systems and anatomical regions, Bones, Open, Other therapeutic substance, Recombinant Bone Morphogenetic protein. Without the procedure description provided for my review It is difficult to answer your question, but it sounds like you referenced your procedure in coding clinic and have your answer to not code separately for that procedure. 30. Is BMP included in the fusion code (as non-autologous tissue substitute) or is it coded separately? Code the fusion to the correct Joint (upper/lower) and select the device non-autologous as the device for BMP if that is the only fusion device being used. If the BMP is being used in conjunction with an IBFD follow the coding clinic guidance and the PCS table. If the BMP is being used and combined with auto graft follow the coding clinic guidance for that example. 31. If there is a diskectomy at L5 and S1, is the diskectomy coded twice? No it is not coded twice see the body part lower Joints selection for Lumbo-sacral Disc This body part covers the joint space between L5-SI 32. We have had cases where bone is harvested from the iliac crest for fusion. Some of the bone is mixed with bmp and returned to the iliac crest (I assume to aid with healing). How would this be coded? 6

7 I don t think this is integral to the harvest of the bone, but would carefully review the procedure documentation for any indication of other objective intended and if appropriate code accordingly. Such as control of bleeding, if it is to promote bone healing add code: 3E0V0GB For Administration, Physiologic Systems and anatomical regions, Bones, Open, Other therapeutic substance, Recombinant Bone Morphogenetic protein. 33. On the Laminectomy operation slide for the L3, L4, L5 Laminectomy, the nerve root compression due to lumbar stenosis. Could you explain the PCS code of 019B0ZZ that falls under drainage? You are correct identifying a typo. The terminology is correct for the release but the character was miss-keyed. The Correct code for the Release is 01NB0ZZ 34. A patient presented with pseudo arthrosis after fusion and had to be redone because the patient, but if the cause is a non-union of bone and the hardware is replaced, how is this coded is this a complication? Pseudo-arthrosis following surgical fusion is by definition considered a complication of spinal surgery and is associated with malunion and instability including problems with pain including new nerve compression or failed relief of existing nerve compression. Similar terminology may be used such as flat back syndrome and failed back syndrome. I would need the record to give you an accurate code assignment; however you may consider the following codes for the described scenario M96.0 Pseudo arthrosis after fusion or arthrodesis, or M96.1 Post laminectomy syndrome, not elsewhere classified 35. Is there an official reference or guideline that states the decompression laminectomy should be coded in addition to the spinal fusion code? I-9 gave us specific guidance NOT to code the decompression laminectomy with the spinal fusion (CC 2Q 1995 pg. 9). Currently one of the coding clinics addresses laminectomy with Decompression, but gives no example of decompression with fusion. I would caution against using I-9 coding clinic for guidance on the coding of I-10 PCS procedures. Review the PCS official coding guidelines which states that for multiple procedure coding the general rule; code separate procedure if a different body part is involved, a different root operation, or a different approach. In the question asked you have two different body parts, two different root operations. I would code both procedures. One objective is to release the spinal structures and one is to fuse the vertebral joints. See coding clinic example of laminectomy with fusion: AHA Coding Clinic for ICD-10-CM and ICD-10 PCS, 2Q 2014, Volume 1, Number 2, Pages I am wondering about the Root Operation for a discectomy when there is documented release of the nerve root which is impinged upon by the herniated or degenerated disc. I.E., Lumbar Disc herniation with Lumbar Radiculopathy/ Radiculitis. Would that still be Excision of disc or would that instead be Release of spinal nerve root? It seems as there could be a double intent depending on how the documentation is phrased. 7

8 Always follow the documented objected in the operative report. The root operation should match the description. If the objective or root operation is not clear review supporting documents and if needed query the surgeon for the objective or missing details. The Coding Clinic directs us that a laminectomy for decompression should be coded to the release of structure being compressed/impinged. 37. We ve noticed something and are wondering if this is correct, or what others are doing regarding the following situation: Operation involves removing previously placed spinal hardware. Surgeon noted that extensive epidural scar was lysed. When coding OSP004Z (removal of spinal hardware) as principal procedure and additional procedure O0NY0ZZ (lysis of epidural scar), our encoder indicates that the DRG will be based upon the lysis of epidural scar rather than the principal procedure. The DRG then goes to a lesser weighted DRG than it would have if the account had only OSP004Z as procedure. Is this correct? It is difficult to give you a DRG calculation without the diagnosis used. If the DRG is linking to the CNS procedure then you need to carefully evaluate the principal diagnosis including the 7 th character encounter which also may impact the DRG assigned. 38. If patient has a deformity such as valgus and it s corrected during an arthroplasty, do we code it as an additional procedure especially if they added screws, etc. to stabilize everything? If a valgus deformity is documented and the objective described includes the repair of the Valgus It would likely be coded. Refer to the PCS coding guidelines for multiple procedures that describe the guideline when other body parts, root operations or approach are used. 39. Same type of thing if an fx is noted while doing a hip arthroplasty and they wrap wires, etc. before they place the inserts, is that coded to fx repairs? It is difficult to give you a PCS answer without an operative report, but will try to answer partially. A Hip arthroplasty may involve the head of the femur and/or the pelvic hip. Identify all of the fractured bones specifically and the objectives for the repairs. If different objectives or different devices are used read carefully the procedure to select root operations and the device(s) used. 40. Are laminectomies and decompressions performed in the process of doing a fusion also coded as separate procedures or are they still considered part of the fusion prep work? I would code both procedures. One objective is to release the spinal structures and one is to fuse the vertebral joints. The objective for the spinal decompression is to free up and remove impingement; the fusion is to permanently render joints immobile. 8

9 See coding clinic example of laminectomy with fusion: AHA Coding Clinic for ICD-10-CM and ICD-10 PCS, 2Q 2014, Volume 1, Number 2, Pages Large osteophytes found when they get into the wound and reamed out considered just one of those things you find and take care of but do not code separately? Would you code to a diagnosis though? Osteophytes requiring removal/destruction should be coded to a vertebrae M These abnormal structures cause pain, reduced motion in joints etc. They also require removal to place certain hardware. 42. Could you please explain fusions when the approach used lateral and they do something on the anterior side and then flip the patient and continue on the back? DBM is not the same as using bone taken from the patient and then put into a suspension and reapplied to a defect area and that is not separately coded as far as I can tell. Joint filler is a type of cement I think so is that a synthetic substitute device? DBM is also a synthetic substitute? Or a non-autologous tissue substitute? DBM is a non-autologous tissue. If DBM is mixed with the patient s own bone and applied, the default is Autologous per the PCS guidelines, and Coding clinic guidance. Joint filler made from cement is a synthetic substitute device. If a patient has an anterior-lateral incision and then is turned over and has a posterior incision the details of the procedure from both incisions is used to identify the Anterior- Posterior Fusion that was performed at the specific vertebral joint level of the spine described in the operative report. 9