Neurosurgery Coding Alert

When a patient needs a spinal fusion procedure, there are a variety of techniques and approaches that your surgeon could use. Which one you choose will depend on how the notes represent the encounter.

ICD-10 code examples:

• S32.00- (Fracture of unspecified lumbar vertebra)
• S32.02- (Fracture of second lumbar vertebra)
• S32.11- (Zone I fracture of sacrum)
• S32.14XX (Type 1 fracture of sacrum)
• S32.16XX (Type 3 fracture of sacrum)

DEGENERATION

ICD-10 code examples:

• M50.320 (Other cervical disc degeneration, mid-cervical region, unspecified level)
• M50.321 (Other cervical disc degeneration at C4-C5 level)
• M51.34 (Other intervertebral disc degeneration, thoracic region)
• M51.36 (Other intervertebral disc degeneration, lumbar region)

RADICULOPATHY

ICD-10 code examples:

• M54.11 (Radiculopathy, occipito-atlanto-axial region)
• M54.13 (Radiculopathy, cervicothoracic region)
• M54.14 (Radiculopathy, thoracic region)

MYELOPATHY

ICD-10 code examples:

• M47.11 (Other spondylosis with myelopathy, occipito-atlanto-axial region)
• M47.12 (Other spondylosis with myelopathy, cervical region)
• M50.02 (Cervical disc disorder with myelopathy, mid-cervical region)
• M50.03 (Cervical disc disorder with myelopathy, cervico­thoracic region)

STENOSIS

ICD-10 code examples:

M48.01 (Spinal stenosis, occipito-atlanto-axial region)

M48.04 (Spinal stenosis, thoracic region)

M48.07 (Spinal stenosis, lumbosacral region)

MISALIGNMENT

ICD-10 code examples:

• M53.2X2 (Spinal instabilities, cervical region)
• M53.2X4 (Spinal instabilities, thoracic region)
• M53.2X7 (Spinal instabilities, lumbosacral region)

DEFORMITY

ICD-10 code example:

• Q67.5 (Congenital deformity of spine)

Note: As Adams said, this is not an all-inclusive list of conditions — or ICD-10 codes — that might justify spinal fusion surgery. Always code to the notes, and check your individual payer policies of you have questions about an ICD-10 code in regards to spinal fusion.

Get Levels, Approach Info for Documentation

You’re also going to need to get specific pieces of documentation about the encounter in order to code spinal fusions correctly, Adams warned. These elements include:

• Approach: Interbody, anterior, posterior interbody, etc.
• What specific level(s): “We need to know what specific levels that we’re working with. Cervical, thoracic, lumbar, sacral but, even more importantly, specifically which vertebra we are working on, so that we know how to count how many interspaces that we’re working with here,” explained Adams.
• Interspace count: “Fusions are always going to be done based on interspaces so you’re going to fuse two vertebrae together you’re going to have to include at least one interspace between them,” said Adams.
• Type of implant(s) or graft(s): Rods, metal plates, screws, cages, autograft (local, structural, morcelized), allograft (structural, morcelized), etc.
• Reason fusion is being done: Degeneration, myelopathy, stenosis, etc.
• Instrumentation: “Is the instrumentation that we’re using new, replaced, or removed?” Adams asked.

Observe These ‘Special’ Spinal Coding Rules

When coding for spinal fusion, there are several rules that you’ll observe that don’t apply to some of the other fusion codes, Adams said.

First, you can report instrumentation separately with fusion codes. Some of the codes for instrumentation you might include on a spinal fusion claim include:

• +22840 (Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation,sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure))
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure))
• +22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instru­mentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure))

Remember: This is not an all-inclusive list of the types of instrumentation your surgeon might employ during spinal fusion. Also, these are add-on codes, meaning you cannot report them as standalone codes. Further, all of the above codes have restrictions on the specific codes you can report with them. For example, the notes under the CPT^® descriptor for +22853 state:

“Use 22853 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-63307”

Report Grafts, Stereotactic Nav Separately, too

In addition to spinal instrumentation, you can also code any grafts the surgeon performs, Adams confirmed. Some of the grafts that could accompany a spinal fusion include:

• +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure))
• +20931 (Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure))
• +20936 (Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure))
• +20939 (Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure))

Remember: This is not an all-inclusive list of the types of grafts that the surgeon might perform in tandem with spinal fusion.

And finally, there’s stereotactic navigation, which you can report with +61783 (Stereotactic computer-assisted (naviga­tional) procedure; spinal (List separately in addition to code for primary procedure)). Remember that this is an add-on code that you cannot report as a standalone.