Anesthesia Coding Alert

The key to successful spine claims can come down to counting.

Coding for spinal treatments can be intricate because of the many anatomical details involved, no matter what the procedure might be. The next time you’re faced with trying to differentiate regions of the spine to correctly report your provider’s service, keep these tips in mind.

Focus on Body Area and Terms

The best way to learn about spinal anatomy is, unsurprisingly, first knowing the terms and body areas associated with each vertebral set, says Lynn M. Anderanin, CPC, CPPM, CPC-I, CPMA, COSC, whose HEALTHCON 2020 presentation “Spinal Surgery Update 2020,” broke down the basics of spinal anatomy coding.

As a quick reference, Anderanin laid out this chart that she uses to introduce coders to spinal anatomy:

The information in the above table can be an invaluable resource when making sense of encounter notes.

Example 1: Notes indicate that the provider treated vertebrae T1, T2, and T3 in the patient’s lumbar area.

Something’s wrong with these notes, as the T spinal segments are thoracic, not lumbar.

Example 2: Notes indicate that the provider treated two coccyx vertebrae in the patient’s tailbone area. These notes make anatomical sense.

Take it from the top: It is useful to know the order that the vertebrae fall along the spine as well, to make sure that you count and catalog segments and interspaces correctly.

From the cervical (neck) area to the sacrum (pelvis) area, the abbreviations are listed thusly:

• C1-C7
• T1-T12
• L1-L5
• S1-S5

This information could be a vital lifeline when choosing codes because it can help you deduce if the encounter notes make sense. If notes indicate that the surgeon treated vertebral discs C2-S1, you might want to check with the provider; this seems a medically unlikely (and huge) area of the spine to treat — it indicates that the surgeon treated nearly 25 vertebrae.

Remember Segment and Interspace Differences

Anderanin also stressed that coders need solid knowledge of the differences between vertebral segments and vertebral interspaces. Without this info, coding spinal surgeries isn’t going to be easy.

Vertebral segment: This term describes the basic parts into which the spine is divided. The word “segment” represents one complete vertebrae and includes any related laminae and articular processes, Anderanin explains.

Vertebral interspace: The non-body compartments between vertebrae are interspaces. The intervertebral disc is in the interspace, as are the nucleus pulposus, annulus fibrosus, and a pair of cartilaginous endplates, Anderanin relays.

So, let’s say notes indicate that the surgeon treated vertebrae L1-L3. Just from this information, you can glean the following if you have spinal anatomy smarts:

• The surgeon treated three vertebral segments: L1, L2, L3.
• The surgeon treated two interspaces: between L1-L2 and L2-L3.