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Housekeeping Items Type them in the chat window. © 2019 Haugen Consulting Group, Inc. 2 © 2019 Haugen Consulting Group, Inc. 1 Backbone of Spinal Fusions PCS Coding Following the webinar Follow up Email: 48 hours Need to register for recording (free) View recording © 2019 Haugen Consulting Group, Inc. 3 The Backbone of Spinal Fusion 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 © 2019 Haugen Consulting Group, Inc. 2 Backbone of Spinal Fusions PCS Coding 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 © 2019 Haugen Consulting Group, Inc. 5 Spinal Regions Breakfast at 7 Lunch at 12 Dinner at 5 © 2019 Haugen Consulting Group, Inc. 6 © 2019 Haugen Consulting Group, Inc. 3 Backbone of Spinal Fusions PCS Coding The Spinal Column Piecing together the puzzle © 2019 Haugen Consulting Group, Inc. 7 The Vertebral Segment Superior View Lateral View Shown: lumbar vertebra © 2019 Haugen Consulting Group, Inc. 8 © 2019 Haugen Consulting Group, Inc. 4 Backbone of Spinal Fusions PCS Coding Intervertebral Disc • Spinal “shock absorber” • Disc components o Outer annulus fibrosus ring o Inner nucleus pulposus © 2019 Haugen Consulting Group, Inc. 9 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 © 2019 Haugen Consulting Group, Inc. 10 © 2019 Haugen Consulting Group, Inc. 5 Backbone of Spinal Fusions PCS Coding Segments vs. Interspaces In ICD‐10‐PCS, for spinal fusion, we count the interspaces, not the segments © 2019 Haugen Consulting Group, Inc. 11 Polling Question #1 Fusion from L1-L4. How many joints were fused? a) 3 b) 4 c) I don’t know © 2019 Haugen Consulting Group, Inc. 12 © 2019 Haugen Consulting Group, Inc. 6 Backbone of Spinal Fusions PCS Coding 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 bone graft © 2019 Haugen Consulting Group, Inc. 13 Upper Joints Fusion (0RG) Vertebral joints above the diaphragm (cervical and thoracic) © 2019 Haugen Consulting Group, Inc. 14 © 2019 Haugen Consulting Group, Inc. 7 Backbone of Spinal Fusions PCS Coding Lower Joints Fusion (0SG) Vertebral joints below the diaphragm (lumbar and lumbosacral) © 2019 Haugen Consulting Group, Inc. 15 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 © 2019 Haugen Consulting Group, Inc. 16 © 2019 Haugen Consulting Group, Inc. 8 Backbone of Spinal Fusions PCS Coding 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 © 2019 Haugen Consulting Group, Inc. 17 The Device Hierarchy Guideline Note: interbody fusion B3.10c devices made of cadaver bone are coded as interbody devices, not nonautologous tissue substitute © 2019 Haugen Consulting Group, Inc. 18 © 2019 Haugen Consulting Group, Inc. 9 Backbone of Spinal Fusions PCS Coding Selecting the Qualifier Operative Approach Column Fused (Anterior/Posterior) (Anterior/Posterior) Anterior Approach Posterior Approach © 2019 Haugen Consulting Group, Inc. 19 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 discectomy description of placement of • Performed to prepare interspace screws and rods for fusion • Look for corpectomy • Removal of the vertebral body • Not always performed, but when done, the remaining bodies are fused © 2019 Haugen Consulting Group, Inc. 20 © 2019 Haugen Consulting Group, Inc. 10 Backbone of Spinal Fusions PCS Coding 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 © 2019 Haugen Consulting Group, Inc. 21 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 © 2019 Haugen Consulting Group, Inc. 11 Backbone of Spinal Fusions PCS Coding 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 © 2019 Haugen Consulting Group, Inc. 23 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 © 2019 Haugen Consulting Group, Inc. 24 © 2019 Haugen Consulting Group, Inc. 12 Backbone of Spinal Fusions PCS Coding Procedures Adjunct to Spinal Fusion Segmental and non‐segmental instrumentation Discectomy Laminectomy/ Laminotomy © 2019 Haugen Consulting Group, Inc. 25 Segmental/Non-segmental Fixation All fixation is integral to spinal fusion* *except for osteotomy with fusion for correction of spinal deformity © 2019 Haugen Consulting Group, Inc. 26 © 2019 Haugen Consulting Group, Inc. 13 Backbone of Spinal Fusions PCS Coding 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) © 2019 Haugen Consulting Group, Inc. 27 Release of Central Nervous System (00N) Release of spinal cord by region © 2019 Haugen Consulting Group, Inc. 28 © 2019 Haugen Consulting Group, Inc. 14 Backbone of Spinal Fusions PCS Coding Release of Peripheral Nervous System (01N) Don’t forget to use the Body Part Key © 2019 Haugen Consulting Group, Inc. 29 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 © 2019 Haugen Consulting Group, Inc. 30 © 2019 Haugen Consulting Group, Inc. 15 Backbone of Spinal Fusions PCS Coding Selecting the Body Part for Discectomy Upper Joints Lower Joints © 2019 Haugen Consulting Group, Inc. 31 Use of BMP for Spinal Fusion • Bone morphogenetic protein (BMP) • Stimulates bone growth,