A: CPT: For pro-fee CPT coding, both surgeons should report the correct anterior approach CPT code with modifier 62 for co-surgeon.
ICD-10-PCS: For the facility, the approach is embedded in the fusion code, so there is no additional code reported for the surgical approach procedure. Some facilities have methods of abstracting assisting surgeons in their abstracting systems without it interfering with code assignment.
Q: When the surgeon documents that he did a fusion of L3-S1, how many fusion codes do we need? Do we count the segments or the joints?
A: An anterior L3-S1 fusion involves 4 segments and 3 joints (L3-L4, L4-L5, and L5-S1).
In ICD-10-PCS, fusion is coded according to the number of joints, however, since one of those joints is a transition joint (L5-S1), it has a different body part. To report anterior fusion of L3-4 and L4-5, the body part is Lumbar Vertebral Joints, 2 or more. The L5-S1 is reported separately with body part Lumbosacral Joint.
In CPT, fusion is counted by interspace. The rationale for not defining the initial level in terms of the vertebral segment is that you cannot fuse the vertebra to itself, therefore you must have at least 2 segments for the initial procedure code. But, after the first two are fused, each time you add one more segment you make another level. Try to count spaces and not focus on CPT's terminology of level and segment. You should have one code corresponding with each interspace fused. This example would have 4 segments, but 3 interspaces, so three levels of fusion.
Q: Can spondylosis be coded in addition to other spinal conditions, such as degenerative disc disease and spondylolisthesis?
A: It is important to follow the Excludes notes in ICD-10-CM to help guide and direct you when reporting multiple codes. In this example, spondylosis, degenerative disc disease, and spondylolisthesis are different conditions and there are no Excludes notes that prevent you from coding them all together.
Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer
Kristi is a senior consultant with more than 20 years of industry experience. She develops and delivers training on ICD-10-CM/PCS and CPT, both virtually and in classroom settings.
Kristi also performs DRG and APC audits and is known for her vast knowledge on coding vascular interventional radiology procedures. Kristi has an extensive background in coding education and consulting and is a national speakers on topics related to ICD-10 and CPT coding as well as code-based reimbursement.