Q: We were originally educating the coders at our facility to code removal of internal fixation device from the joint per Coding Clinic 2Q 2017 pgs. 23-24 however a correction was issued in Coding Clinic 2Q2019 that states to use body part of vertebrae. But you’re saying to code to "joint"?
A: After review of these Coding Clinic articles, we agree that the body part for removal of internal fixation from a previous spinal fusion procedure should be reported with a body part from the Upper Bones or Lower Bones tables.
Q: From your previous presentation, it was stated a corpectomy should not be coded when performed with a fusion unless for example done to remove a tumor. Why is excision of disc coded separately during a fusion but not a corpectomy? The intent of the procedure is the same - to fuse the spine?
A: There is no official guidance for reporting corpectomy when performed in addition to a spinal fusion. After discussion with other spinal fusion coding experts, we agreed that removal of bone is always necessary to prepare the joint for fusion. Except for corpectomy for a malignancy, the intent of the procedure is to fuse the joint. With a malignancy, the intent of the procedure is to remove the neoplastic tumor before fusing the spine. As for discectomy, there is official advice that states that it should be reported in addition to spinal fusion, even though one could argue that it is necessary to prepare the interspace for spinal fusion. We submitted a letter to Coding Clinic asking for clarification and will update our advice once we receive an answer.
Updated 1/24/22: In the two operative reports we sent as supporting documentation with the question, Coding Clinic responded that corpectomy was done for decompression and it should be reported with root operation "Release." They did not recommend coding corpectomy to the root operation Excision or Resection. Based on this advice, each operative report would stand on its own. If its documented that the corpectomy was performed to release a nerve root or spinal cord, it is coded to Release.
Q: After a corpectomy is performed and the vertebrae are repositioned, a physician will document that the anterior fusion was performed with "apposition" however they don't indicate bone graft was placed. Is it proper to call that a fusion?
A: Apposition is defined as the process of placing in juxtaposition or proximity. This means that the surgeon is positioning the spine into proper alignment and is not the same as fusion. Without specific documentation that bone graft was used, this should not be coded as a spinal fusion. In addition to the operative report, a spinal implant log may contain additional information about whether bone graft material was used.
Q: I have a doctor who wants an osteotomy coded but he does not document any spinal deformity. Can you code the osteotomy in that case?
A: In ICD-10-PCS, root operations are assigned based on procedural intent. In our discussion on osteotomies for correction of spinal deformities, the intent of the osteotomy procedure is to bring the spine into proper alignment. As such, the root operation for osteotomy for spinal deformity is Reposition. If there is no spinal deformity documented, we recommend querying the surgeon for the intent of the osteotomy. If there is no spinal deformity, then the Reposition root operation would not be appropriate.
Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer
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.