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The Backbone of ICD‐10‐PCS Kristi is a Senior Consultant with more than 20 years of industry experience; she is responsible for the Coding development of web‐based and instructor‐led training material, conducting training in ICD‐10‐CM/PCS and CPT, and performing DRG and APC audits. Kristi is a Colorado native who has never skied! In her spare time, she partakes in outdoor activities that do not involve strapping two boards to her feet and barreling down a slippery slope. She also enjoys mentoring new coders and Kristi Pollard, RHIT, CCS, CPC, CIRCC spending time with her family. Senior Coding Consultant AHIMA‐Approved ICD‐10‐CM/PCS Trainer February 21, 2019

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Agenda Review spinal and vertebral anatomy

Describe different methods of achieving spinal fusion

Describe various devices used in spinal fusion

Assign ICD‐10‐PCS codes to spinal fusion cases

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Spinal Regions

Breakfast at 7

Lunch at 12

Dinner at 5

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The Spinal Column

Piecing together the puzzle

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The Vertebral Segment Superior View Lateral View

Shown: lumbar vertebra

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Intervertebral Disc • Spinal “shock absorber” • Disc components o Outer annulus fibrosus ring o Inner nucleus pulposus

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Spinal Nerves and Plexuses

Don’t forget the body part key!

Examples: • First intercostal nerve = Brachial Plexus • Other intercostal nerves = Thoracic Nerve • Solar (celiac) plexus = Abdominal Sympathetic Nerve

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Segments vs. Interspaces

In ICD‐10‐PCS, for spinal fusion, we count the interspaces, not the segments

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Polling Question #1

Fusion from L1-L4. How many joints were fused? a) 3 b) 4 c) I don’t know

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Spinal Fusion • Root Operation: Fusion • Body System: Upper or Lower Joints

• Procedure Intent: To render the joint immobile • Technique: “weld” two or more vertebral segments together using devices and/or graft

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Upper Joints Fusion (0RG)

Vertebral joints above the diaphragm (cervical and thoracic)

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Lower Joints Fusion (0SG)

Vertebral joints below the diaphragm (lumbar and lumbosacral)

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Selecting the Body Part

• Count spaces, not segments • Watch for transitional joints • Example: Fusion of L4-S1 L4 • Fusion of 1 lumbar joint (L4-5) • Fusion of 1 lumbosacral joint (L5-S1) L5

Guideline B3.10a S1

There is only 1 lumbosacral joint in the body

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Selecting the Device “No Device” is not an option as of 10/1/18. All fusions require devices!

Autologous/ Nonautologous Tissue Substitute

Interbody Fusion Device

Synthetic Substitute

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The Device Hierarchy

Guideline Note: interbody fusion B3.10c devices made of cadaver bone are coded as interbody devices, not nonautologous tissue substitute

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Selecting the Qualifier

Operative Approach Column Fused (Anterior/Posterior) (Anterior/Posterior)

Anterior Approach

Posterior Approach

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Qualifier Documentation Clues Subtle! Anterior Column Fusion Posterior Column Fusion

• Look for interbody fusion • Look for use of bone graft device • e.g., bone graft was packed into • They are only used on the the posterolateral gutter anterior spine • Note there will often be more • Look for description of placement of • Performed to prepare interspace screws and rods for fusion • Look for • Removal of the vertebral body • Not always performed, but when done, the remaining bodies are fused

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Interbody Fusion Approaches These are all fusions on the Procedure Operative Approach PCS anterior column Qualifier Anterior lumbar Incision made in front of Anterior interbody fusion (ALIF) the spine through a small incision (minilaparotomy) or through a laparoscopy Posterior lumbar Incision made through a Posterior interbody fusion (PLIF) midline incision in the back Extreme lateral Incision made in the Anterior interbody fusion (XLIF) patient’s side Direct lateral interbody Incision made in patient’s Anterior fusion (DLIF) side Transforaminal lumbar Incision made through a Posterior interbody fusion (TLIF) posterior approach

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When Do You Need More Than One Code? • Separate codes are Focus on the needed for Qualifier! • Fusion of multiple joints with • Different device, and/or • Different qualifier Guidelines • In other words… • Both anterior and posterior B3.2a and approaches, and/or B3.10b • Both anterior and posterior column • Don’t forget that the same procedure on separate body parts is coded separately also © 2019 Haugen Consulting Group, Inc. 22

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360-Degree Fusion

Fusion of both anterior and posterior columns during same operative session

Requires at least two codes (different qualifiers)

May be performed solely from a posterior approach or a combined anterior/posterior approach

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Polling Question #2

Which one of these procedures is technically possible? a) Interbody fusion of posterior spine b) Fusion with no device c) Anterior fusion from posterior approach

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Procedures Adjunct to Spinal Fusion

Segmental and non‐segmental instrumentation Discectomy /

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Segmental/Non-segmental Fixation

All fixation is integral to spinal fusion*

*except for with fusion for correction of spinal deformity © 2019 Haugen Consulting Group, Inc. 26

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Decompressive Laminectomy/ Laminotomy

• Procedure Intent • Release pressure on the spinal cord or nerve roots • Technique • Partial or complete removal of the lamina • Root Operation: Release • Body System: Central or Peripheral Nervous System • Documentation Clues • Decompression, decompressive • What is being released? • Spinal cord (central) • Spinal nerve(s) (peripheral)

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Release of Central Nervous System (00N)

Release of spinal cord by region

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Release of Peripheral Nervous System (01N)

Don’t forget to use the Body Part Key

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Discectomy

• Procedure Intent • Remove part or all of the intervertebral disc in preparation for spinal fusion • Root Operation: Excision or Resection • Body System: Upper or Lower Joints • Coded separate from fusion procedure

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Selecting the Body Part for Discectomy

Upper Joints Lower Joints

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Use of BMP for Spinal Fusion

• Bone morphogenetic protein (BMP) • Stimulates bone growth, often without need for autologous bone graft • BMP‐2 is FDA‐approved for use in titanium cylindrical cages for ALIF • From Guideline B3.10c: • 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 • Use of BMP is included with bone graft and/or interbody fusion device • Coding for administration of BMP is optional • 3E0U0GB, Introduction of recombinant bone morphogenetic protein into joints, open approach

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Case 1: 360-Degree Lumbar Fusion

DIAGNOSES: 1. Unstable lumbar spondylolisthesis at L3-L4 and L4-L5. 2. Lumbar spondylosis with bilateral lower extremity radiculopathy. PROCEDURE: 1. L3, L4, and L5 laminectomy. 2. Bilateral medial facetectomy at L3-L4 and L4-L5. 3. L3-L4 and L4-L5 posterior lumbar interbody fusion. 4. Minimally invasive posterior lumbar instrumented fusion at L3, L4, and L5, with Globus robotic navigated assist. 5. Autograft harvest from the same incision. 6. Bone marrow aspiration from the left iliac bone. INDICATIONS: Chronic low back pain radiating to the buttock and down the proximal posterolateral thigh with failed conservative therapy. MRI shows diffuse degenerative joint and disc disease at the lumbar spine with dynamic instability pattern and spondylolisthesis.

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Case 1: Approach, Robot, and Pedicle Screw Fixation

PROCEDURE DESCRIPTION: The patient was brought to the OR after obtaining informed consent. Timeout was performed and general ET tube anesthesia was induced with all lines previously placed by anesthesia. He was then transferred to the Jackson table in a prone position. All pressure points were padded. was performed with the Globus Excelsius stereotactic robot computer. A preoperative CT scan without contrast was obtained preoperatively and screw trajectory was planned. At this time, a midline incision was marked at the lumbar spine from L3 all the way down to L5. The C-arm was brought in and 2 reference arrays were placed on the patient's bilateral posterior superior iliac spine. AP and lateral fluoroscopy were then obtained of the L3, L4, and L5 vertebral bodies. Images were then merged with the preoperative CT scan with excellent merging in all projections. The robot was then placed into position and the articulating arm was used to help carry out the previously planned screw trajectories. An incision was made with a 15 blade to allow accommodation of the MIS instruments. A drill was used to pass through the pedicles into the vertebral body. The pedicle was tacked, followed by placement of the MIS CREO screw with the tulip sleeves sticking out of the skin. Next, the right L3, then the right L4, left L4, left LS, and finally the right LS screws were placed percutaneously. AP and lateral fluoroscopy was performed and confirmed excellent screw placement. Intraoperative neuromonitoring was performed for each screw as it was tapped and after screw placement. There was no response at 20 milliamps.

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Case 1: Decompressive Laminectomy with Interbody Fusion

We now removed the 2 reference arrays. Attention was focused on the decompressive laminectomy. A midline incision was made from L3-L5. Subperiosteal dissection was performed to expose the lamina bilaterally at L3, L4, and LS. We noted instability at the posterior elements. Fluoroscopy was used to localize and confirm the level. The facet capsule at L2-L3 and LS-S1 were intact. Decompressive were performed at L3, L4, and L5. Medial facetectomy was performed bilaterally. The neural foramen was decompressed. Once satisfied that there was no longer any nerve root compression, copious irrigation was undertaken. The Aquamantys system and OrthoPAT were used throughout surgery. Intraoperative imaging was used to confirm the L3-L4 and L4-L5 disc space. Discectomy was performed bilaterally. Endplates were then rasped after disc material was removed. was performed at the L3-L4 and L4-L5 interspace. All bone removed during the laminectomy and facetectomy was saved as autograft and morselized for later bone graft substrate. Bone marrow aspiration was performed at the left iliac bone. The morcellized autograft and bone marrow aspirate was mixed with KINEX. The bone graft substrate material was used to pack the anterior disc space at both levels. Approximately 4-5 ml was used at each level. Posterior lumbar interbody devices were inserted at bilateral L3-L4 and L4-L5 disc space. The Globus RISE titanium cages were used. The cages were expanded.

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Case 1: Tightening of Rods and Posterior Fusion

Once fluoroscopy confirmed adequate placement of the graft and that it was situated anteriorly and expanded enough, MIS rods were placed. The lordotically curved rods were placed into the tulips of each screw on both sides. The rods were then tightened down and all cap screws were finally torqued in place. Final fluoroscopic imaging was obtained in the AP and lateral view, demonstrating proper placement of the interbody cages, pedicle screws and rods. Copious irrigation was again undertaken. All pedicles were assessed to ensure that there was no medial breach. None was noted. Posterior and posterolateral arthrodesis was performed at bilateral L3, L4, and L5 using locally obtained bone graft. After the surgical site was assessed and hemostasis was achieved, Tisseel was used to help protect the dura. 2 wound drains were placed into the wound cavity and tunneled out the skin. Final inspection was performed to ensure that there was no residual bone fragments on the thecal sac. We now focused our attention on closing. The layers were closed in sequential anatomical fashion. The patient was extubated in the OR without incident and was moving all 4 extremities antigravity and spontaneously.

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Case 1: The Codes

• Anterior Interbody Fusion L3‐4 and L4‐5 • 0SG10AJ, Fusion 2 or More Lumbar Vertebral Joints with Interbody Fusion Device, Posterior Approach, Anterior Column, Open • Posterior Fusion L3‐4 and L4‐5 • 0SG1071, Fusion of 2 or More Lumbar Vertebral Joints with Autologous Tissue Substitute, Posterior Approach, Posterior Column, Open • Decompressive Laminectomy • 01NB0ZZ, Release Lumbar Nerve, Open Approach • Discectomy • 0SB20ZZ, Excision of Lumbar Vertebral Disc, Open Approach • Bone Marrow Harvest • 0QD30ZZ, Extraction of Left Pelvic Bone, Open Approach • Robotic Assist • 8E0W0CZ, Robotic Assisted Procedure of Trunk Region, Open Approach

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Fusion: New Technologies (XRG Table)

These codes describe the • Nanotextured Surface complete procedure. Do not • nanoLock® surface technology assign codes from 0RG/0SG • Radiolucent Porous table separately • Cohere® porous PEEK technology • COALESCE™ porous PEEK interbody fusion device

Vertebral joints from Occipital‐cervical Joint to Lumbosacral Joint

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Polling Question #3

Harvesting of local bone graft is coded separately from the fusion. a) True b) False

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Osteotomy with Fusion for Scoliosis/ Kyphosis

• Procedure Intent • Reposition the spine into proper alignment and fuse the joints • Root Operations • Reposition of Upper/Lower • Fusion of Upper/Lower Joints

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Case 2: Ponte Osteotomy and Fusion

Preoperative Diagnosis: Adolescent idiopathic scoliosis Postoperative Diagnosis: Adolescent idiopathic scoliosis Procedure: 1. Application of Gardner-Wells tongs with removal. 2. Posterior spinal fusion from T2-L4 3. Posterior segmental instrumentation from T2-L4 4. Ponte of thoracic and lumbar spine 5. Autograft for spine only morselized 6. Allograft for spine only morselized Procedure Description: After informed consent was obtained, the patient was brought to the OR where she was placed under general anesthesia. An arterial line and 2 IVs were placed along with a Foley catheter. Gardner-Wells tongs were placed at the appropriate fashion using a Betadine skin prep. All bony prominences were well-padded and the skin was protected with Allevyn padding. © 2019 Haugen Consulting Group, Inc. 41

Case 2: The Approach

Neuromonitoring was carried out throughout the case. We were able to obtain baseline motors and SSEPs and there were no changes throughout the case. Patient was then placed prone on the Jackson table and 10-15 pounds of traction were placed off the head of the bed. The back was then prepped and draped in standard surgical fashion. Quarter percent Marcaine with epinephrine was injected into the incisional area. Longitudinal incision was made over the posterior spine. Dissection was carried down through subcutaneous tissues to the fascia and Bovie electrocautery was used to maintain hemostasis. The spine was then exposed from transverse process to transverse process from T2 down to L4. Facetectomies were then performed at each of the levels from T2 down to L3. This was performed using a bone scalpel and rongeur. At this point it was noted that there was a small dural tear of less than 2 mm at the T12 level. This was repaired later in the case.

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Case 2: Repositioning of Spine with Instrumentation

Ponte osteotomies were performed at each of the following levels: T4, T5, T6, T7, T8, T10, T11, T12, L1, and L2. Both the superior and inferior facets were resected at that point and the ligamentum flavum spinous process was resected at each level and harvested for autograft along with the transverse processes. This was morselized on the back table. Instrumentation on the left consisted of a pedicle screw at T2, T3, T4, T5, and T7 with a sublaminar band placed at T8 and T9. A pedicle screw was placed at T10, T11, T12, L1, L2, L3, and L4. On the right side, pedicle screws at T2 with sublaminar bands placed at T4, T5, T6, T7, T9, T11, T12, and L1 with pedicle screws placed at L2, L3, and L4. Initially, the left rod was inserted. This was a 6 mm cobalt chrome rod. Differential contouring was carried out, bending and increasing the amount of kyphosis into this left rod and lordosis. Gemini reduction devices were attached to each screw and the spine was slowly reduced to the rod. Set screws were applied at each level, including tensioning of the bands at T8 and T9.

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Case 2: Repositioning of Spine with Instrumentation (cont.)

The second rod was then inserted with less amount of kyphosis and lordosis on the right side and this was locked down at each level with set screws and tensioning each of the bands throughout the thoracic spine and reduction devices to reduce the rods to the pedicle screws in the lumbar spine and at T12. At that point in the case, an intraoperative film was taken and direct vertebral body derotation was performed segmentally at each level starting with the most neutral distal level locking down the set screws again with final tightening. Neuromonitoring was rechecked at this time and good correction was noted to have been obtained and there were no changes in the neuromonitoring. Final tightening of all the set screws was performed and tensioning of the bands with compression and/or distraction having been performed. The would was irrigated with normal saline.

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Case 2: Repair of Dural Tear and Posterior Fusion

At this point in time, the small dural tear at T12 was exposed by resecting a portion of the lamina. Interrupted 4-0 Nurolon sutures were then placed x2 to gain good closure. DuraSeal was applied along with a DuraGen patch. DuraSeal was then applied again to the area. Decortication of the spine was then carried out along with . The bone graft was laid down using both autograft and 30 cc of allograft from T2 to L4, which had been mixed with vancomycin powder. The autograft had been mixed with the InQu bone graft extender and substitute. A deep drain was placed and brought out the left side. The fascia was closed with 0 Vicryl suture 1 g of vancomycin powder was placed in the subcutaneous tissue. 2-0 Vicryl suture was used to close subcutaneous tissues and 2-0 Quill to close the skin. Sterile dressings were applied. The Garner-Wells tongs were removed at the completion of the case. The patient was awakened and transferred to recovery in stable condition.

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Case 2: Coding the Osteotomy

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Case 2: Coding the Fusion

• 10 Thoracic vertebral joints (T2‐T12) • 1 Thoracolumbar joint (T12‐L1)

3 Lumbar vertebral joints (L1‐L4)

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Case 2: The Codes

• Osteotomy • 0PS404Z, Reposition Thoracic Vertebra with Device, Open Approach • 0QS004Z, Reposition Lumbar Vertebra with Internal Fixation Device, Open Approach • Fusion • 0RG8071, Fusion 8 or More Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior Approach, Posterior Column, Open • 0RGA071, Fusion Thoracolumbar Vertebral Joints with Autologous Tissue Substitute, Posterior Approach, Posterior Column, Open • 0SG1071, Fusion 2 or More Lumbar Vertebral Joints with Autologous Tissue Substitute, Posterior Approach, Posterior Column, Open • Dural Repair • 00UT0KZ, Supplement Spinal Meninges with Nonautologous Tissue Substitute, Open Approach

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References

• 2019 ICD-10-PCS code set • 2019 ICD-10-PCS Official Guidelines for Coding and Reporting • Coding Clinic for ICD-10-CM/PCS

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Thank you!!

Kristi Pollard, RHIT, CCS, CPC, CIRCC [email protected]

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