Neurosurgery Coding Alert

Get to know the spine in-depth, and the right codes will follow

Do you know your facet from your transverse process? Your lamina from your occiput? If not, it's time for a quick reminder of how these structures work, and you-ll increase your coding savvy quickly and easily.

Because your surgeon won't always dictate his notes using the same terms you-ll see in the CPT and ICD-9 manuals, a firm grasp of anatomic knowledge is important. In the next few issues, Neurosurgery Coding Alert will give you the tools you need to connect anatomic terminology to the right diagnosis and CPT codes. In this issue, we-ll break down the spine and how each term fits into your claims process.

The Spine -- a Primer

The vertebral column is made up of 33 vertebrae: seven cervical, 12 thoracic, five lumbar, five sacral, and four coccygeal (with sacral and coccygeal fusing into one bone mass). Anatomically, the spine is divided into four main sections:

Cervical -- The cervical spine begins at the base of the skull (occiput) and contains seven vertebrae and eight pairs of cervical nerves that control the neck, arms and upper body. The seven cervical vertebrae are referred to as C1-C7. Injuries to this portion of the spine can result in radiating pain in the neck (723.1), shoulder (719.41) and upper extremities.

Where you might see it referenced: A problem that neurosurgeons see in the cervical spine is cervical stenosis, which occurs when the spinal canal or neural foramen narrows. Surgeons may treat this with surgery such as a cervical laminectomy (63045), says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Thoracic -- The thoracic spine is the midsection of the spine, and contains 12 vertebrae (T1-T12) and 12 pairs of ribs and nerves that control the body's midsection. Because this portion of the spine is stabilized by the rib cage, injuries are less common than at the cervical or lumbar spine.

Why it's important: Physicians may treat thoracic discogenic pain syndrome (such as 722.11) by performing a thoracic discectomy (63077-63078).

Lumbar -- Near the bottom of the spine -- its strongest region -- is the lumbar spine. There are five lumbar vertebrae designated L1-L5 and five pairs of lumbar nerves that control movement and sensory function in the lower extremities. The lumbar region carries the bulk of the body's weight and is a common injury site. Injuries to this area can cause radiating pain or sciatica (724.3) in the legs, as well as pain in the distant lower extremities.

What you might see in this region: The surgeon might perform lumbar laminotomy and discectomy (63030, Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, lumbar [including open or endoscopically assisted approach]) to treat a herniated lumbar disc.

Sacral -- The lowest part of the spine is the sacrum, which includes five bones that are fused together, known as S1-S5. Facet joint injections (64475-64476) are common procedures in the sacral spine to treat sacroiliac joint syndrome (724.6).

Below the sacrum is the bone known as the coccyx, which is the bottom of the spinal column and is also known as the tailbone.

The spinal column includes more than bones: The non-bony area between vertebrae is called a vertebral interspace. In surgical terms, aspects of the back are operated on and so designated based on the numerical system (C2, L5, etc.). Consequently, when an op report indicates that a surgery took place at L5-S1, the region is the fifth lumbar vertebra, including the interspace between L5 and S1 (or sacrum) consisting of the disc and/or facet joint(s), depending on the surgical approach.

A surgery at C7-T2 includes three vertebrae (segments) and two interspaces, from the seventh cervical to the second thoracic, including the first thoracic between them.

Each vertebra is made up of several parts, any or all of which may come into play during a spinal procedure:

 - Vertebral body -- The largest part of the vertebra, the vertebral body is a thick block of bone on the front, or anterior side, of the spine and is the primary weight-bearing area of the spinal column.

 - Spinous process -- The large bony protrusion you feel when running your hand down your back, the spinous process forms the back of the vertebra.

 - Transverse process -- On either side of the spinous process at 90-degree angles, the transverse processes are two bony protrusions that back muscles attach to.

 - Foramen -- This is the opening between the vertebrae through which a spinal nerve passes.

 - Lamina -- The lamina is the protective bony covering of the spinal canal posteriorly.

 - Facet joints -- Four facet joints, two on the top and two on the bottom of each vertebra, interlock to connect the vertebrae to one another.

 - Intervertebral disc -- The space between each vertebra is separated by intervertebral discs that cushion the bones.

When a disc herniates or ruptures, the soft nucleus or degenerated annulus spurts out through a tear in the annulus and can compress a nerve root. Surgeons may perform laminotomy (such as 63020-63044) or microdiscectomy for this, Corcoran says.