1. Spinal Procedure Coding in ICD 10
Linda Dawson, RHIT, CCS, I-10 CM/PCS Trainer
IP Coding QI Compliance Auditor and Trainer

2. Functions of the vertebral column
Protection: Encloses and protects the spinal cord within the spinal canal. Support: Carries the weight of the body above the pelvis. Axis: Forms the central axis of the body. Movement: Has roles in both posture and movement.

3. Anatomy of the vertebrae
(Spinous process)
Pars interarticularis

4. Anatomy of the Vertebrae
Superior View
Body: The body is the largest part of a vertebra, it is slightly cylindrical in shape, and faces interior of body. Its upper and lower surfaces are flattened and rough, and each presents a rim around its circumference.
Foramen: A natural opening or passage, through a bone
Pedicles: The pedicles are two short, thick processes, which project backward, one on either side, from the upper part of the body, at the junction of its posterior and lateral surfaces. The concavities above and below the pedicles are named the vertebral notches.
Laminae: The laminae are two broad plates directed backward and medial ward from the pedicles. They fuse in the middle line posteriorly, and so complete the posterior boundary of the vertebral foramen.
Spinous Processes: The spinous process is directed backward and downward from the junction of the laminae, and serves for the attachment of muscles and ligaments.
Articular Processes: The articular processes, two superior and two inferior, spring from the junctions of the pedicles and laminae. The articular surfaces are coated with hyaline cartilage.
Transverse Processes: The transverse processes, two in number, project one at either side from the point where the lamina joins the pedicle. 

5. Anatomy of the Vertebra
Lateral view. Anterior side is the body, the posterior side the spinous process.

6. Anatomy of the Vertebra

7. Vertebral Terminology
Body: The body is the largest part of a vertebra, it is slightly cylindrical in shape, and faces interior of body. Its upper and lower surfaces are flattened and rough, and each presents a rim around its circumference.
Foramen: A natural opening or passage, through a bone
Pedicles: The pedicles are two short, thick processes, which project backward, one on either side, from the upper part of the body, at the junction of its posterior and lateral surfaces. The concavities above and below the pedicles are named the vertebral notches.
Laminae: The laminae are two broad plates directed backward and medial ward from the pedicles. They fuse in the middle line posteriorly, and so complete the posterior boundary of the vertebral foramen.
Spinous Processes: The spinous process is directed backward and downward from the junction of the laminae, and serves for the attachment of muscles and ligaments.
Articular Processes: The articular processes, two superior and two inferior, spring from the junctions of the pedicles and laminae. The articular surfaces are coated with hyaline cartilage.
Transverse Processes: The transverse processes, two in number, project one at either side from the point where the lamina joins the pedicle. 

8. Diagnoses for Spinal Fusions
Spondylolisthesis – forward displacement of one vertebra over another, usually of the fifth lumbar over the body of the sacrum, or of the fourth lumbar over the fifth, usually due to a developmental defect in the pars interarticularis.
Spondylosis – (arthritis) with or without myelopathy (any functional disturbance or pathological change in the spinal cord) or radiculopathy (disorder of the spinal nerve roots)
Degenerative Disc Disorders (DDD) with or without myelopathy or radiculopathy
Spinal instability – unstable spine due to disc disorders
Stenosis – narrowing of the vertebral canal, nerve root canals, or intervertebral foramina of the lumbar spine, caused by encroachment of bone upon the space; symptoms are caused by compression of the cauda equina and include pain, paresthesias, and neurogenic claudication. The condition may be either congenital or due to spinal degeneration.
Spinal cord M48--
Neural canal – nerve M99.5-
** spinal stenosis is coded in I-10, whereas it was not coded in I-9.
** There is no code for neurogenic claudication in I-10. (per 3M)
2018 Codes will include specificity of “neurogenic claudication.”

9. Congenital scoliosis is a cc
> Narrowing of thoracic cage leading to abnormal cardiovascular and pulmonary function Complications of scoliosis: > Restrictive lung disease, dyspnea on exertion, pulmonary hypertension, cor pulmonale, and alveolar hypoventilation
Congenital scoliosis is a cc
Q67.5

10. Synovial Cyst of Spine
A synovial cyst of the spine is a fluid-filled sac that develops along the spine. It’s the result of degeneration of a facet joint of the vertebrae of the spine. Most synovial cysts develop in the lumbar spine.
M71.38, Other bursal cyst, other site

11. Preexisting/Spinal related MCC/CC Diagnoses
Vascular myelopathy MCC – G95.19
An abnormality of the spinal cord in regard to its blood supply.
Edema of the spinal cord – (vascular) (non-traumatic)
Hematomyelia
Nonpyogenic intraspinal phlebitis/thrombophlebitis
Subacute necrotic myelopathy
Edema of the spinal cord due to trauma CC – S340.1XA lumbar spinal cord
This could be due to a current injury of the spinal cord or late effect of trauma to the spinal cord.
If spinal cord edema is documented with or without a previous spinal injury, query the physician to see if the edema is traumatic or non-traumatic and if the edema is considered to be clinically significant affecting patient care.

12. MCC Diagnoses G95.19 Edema of the spinal cord (vascular myelopathy) (nontraumatic)
INDICATIONS:  This is a lady with progressive myelopathy.  She has  advanced degenerative changes throughout her cervical spine, but at C4-5  there is a bulging disc and compression of the spinal cord with some  mild edema.
Physiology: Cervical myelopathy begins with compression of the spinal cord
in the cervical spine. Edema begins to build about the spinal cord as the cord
attempts to protect itself. This edema appears as white in a t2-weighted
MRI images.
3M Response to question:
I would recommend a query to the physician to determine if the spinal cord edema was clinically significant or an expected response from degenerative disk disease with  myelopathy.
The spinal cord edema would need to meet the criteria for reporting as a secondary diagnosis.  In my opinion, a separate code (G95.19) for spinal cord edema would be appropriate if the edema was considered to be clinically significant; there are no exclusion notes regarding the assignment of codes from category M51.- and G95.19.

13. CC Diagnoses
Fracture of the vertebrae in a patient due to osteomyelitis:
Fx – pathological M84.68
Osteomyelitis - CC
Myelomalacia - CC
Morbid softening of the spinal cord.
Accidental pucture of the dura during a procedure G97.41

14. Coding Clinic
Cervical Disc Disorders ICD-10-CM/PCS Coding Clinic, First Quarter ICD Page: 17 Effective with discharges: March 18, 2016 Question: The instructional note at category M50, Cervical disc disorders states, "Code to the most superior level of disorder." Coders at our facility are trying to interpret this instruction for assigning codes for cervical disc disorders. Does this directive apply only to adjacent levels? If several regions are affected, involving different levels (e.g., C3-C4 and C5-C6), is the code for only the most superior level assigned or can both levels be coded? Answer: The intent of the note is to code each disorder at the highest (most superior) level. Each fourth digit subcategory describes a unique disorder, so within each subcategory, code to the highest level. For example, if several regions are affected (e.g., C3-C4 and C5-C6) that are classified to the same subcategory (e.g., M50.0), assign code M50.01, Cervical disc disorder with myelopathy, high cervical region, as C3-C4 is the most superior level.

15. 2018
ICD 10-CM
Code changes

16. Neurogenic claudication
A new code will be available to show spinal stenosis with neurogenic claudication.
M Spinal stenosis, lumbar region, without
neurogenic claudication
M Spinal stenosis, lumbar region, with

17. 2018 DRG changes
There will be DRG changes as a result of corrections to the PCS code tables for fusions in 2018.
Several spinal fusion levels listed “posterior column” portion of the spine as an option for fusion with interbody fusion devices.
As we know the IBFD’s are only used on the
anterior portion of the spine so the PCS code tables
had errors which will now be corrected.

18. Classification System
Spinal Fusions
ICD 10 Procedure
Classification System

19. https://www. google. com/url
https%3A%2F%2Fs3.amazonaws.com%2Flowres.cartoonstock.com%2Fhealth-beauty-explosion-detonate-overreaction-scare-unnerve-dgrn346_
low.jpg&psig=AFQjCNFnUrG0le0FfVm7Ws3F_1sZeoJAeQ&ust= &cad=rjt

20. Root Operation The Root Operation for Spinal Fusion is Fusion:
Fusion (G) – Joining together portions of an articular body part rendering the articular body part immobile.
The body part is joined together by fixation device, bone graft, or other means.
Fusion procedures are only performed on joints.

21. ICD-10-PCS Coding Guidelines
Fusion procedures of the spine
B3.10a
The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e.g. thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level.
Example: Body part values specify Lumbar Vertebral Joint, Lumbar Vertebral Joints, 2 or More and Lumbosacral Vertebral Joint.

22. What to Code Spinal Fusion Guideline – B3.10B
If multiple vertebral joints are fused a separate procedure is coded for each vertebral joint that used a different device and/or qualifier.
Example: Fusion of lumbar vertebral joint, posterior
approach, anterior column
Fusion of lumbar vertebral joint, posterior
approach, posterior column
The Qualifier is the approach and the column, 2 codes for this example:
0SG00A0
0SG00Z1
This example
DRG 455

23. Body Part Values Upper 7 cervical Cervicothoracic 12 thoracic
B2.1b
Where the general body part values “upper” and “lower” are provided as an option in the Upper Arteries, Lower Arteries, Upper Veins, Lower Veins, Muscles and Tendons body systems, “upper” or “lower “specifies body parts located above or below the diaphragm respectively.
Example: Vein body parts above the diaphragm are found in the Upper Veins body system; vein body parts below the diaphragm are found in the Lower Veins body system.
Lumbar spine
Thoraco-lumbar 5
lumbar
lumbosacral 2
sacral 1
coccyx
Lower

24. Upper Joints

25. Lower Joints

26. Incisions for the Procedure
The (incisional) approach to the procedure is included in the 7th character of the code. Anterior – front of body Posterior – back of body

27. 7th Character- Approach Portion of Spine Fused
Posterior approach, Anterior column
PLIF: Posterior Lumbar Interbody Fusion
TLIF: Transforaminal Lumbar Interbody fusion
Anterior approach
Anterior Column
Posterior approach
Posterior column
XLIF: Extreme Lateral Interbody fusion
DLIF: Direct Lateral Interbody Fusion
Posterolateral Fusion
Procedure are sometimes performed posterior approach on the anterior column

28. Qualifier
Anterior Approach, Anterior Column: access through the front of the body to perform a procedure in the body of the vertebrae or the disc.
Posterior Approach, Posterior Column: access through the back of the body to perform a procedure on the vertebral foramen, spinous processes, facets, and or lamina.
Posterior Approach, Anterior Column: access through the back of the body to perform a procedure on the body of the vertebrae or the disc.

29. Cervical and Thoracic Spinal Fusion
ICD-10-CM/PCS Coding Clinic, First Quarter 2013 Pages: Effective with discharges: March 27, 2013
Question:
A patient is diagnosed with C7-T1 nucleus pulposus herniation with associated impingement upon the exiting left C8 nerve root, and C8 radiculopathy with associated weakness. Provider documentation indicates Smith-Robinson approach to the anterior cervical spine, discectomy, use of local autograft, placement of interbody allograft cage packed with DBX (demineralized bone matrix), placement of interbody spacer for arthrodesis, and placement of Vectra Synthes plate and screws instrumentation. What is the correct ICD-10-PCS code for the spinal fusion?
Answer:
Assign code 0RG40A0, Fusion of cervicothoracic vertebral joint with interbody fusion device, Anterior approach, Anterior column, Open approach, for fusion of one joint between C7 and T1.
"Cervicothoracic vertebral joint" is the distinct body part value for the single vertebral joint (C7-T1) rendered
immobile by the spinal fusion.
"Interbody fusion device" is the device value, since interbody fusion devices (interbody spacer, interbody cage)
and bone graft (local autograft) were used to render the joint immobile.
Anterior approach anterior column is the qualifier, since "Smith-Robinson approach to the anterior cervical
spine, C7-T1 anterior cervical discectomy" is documented.
ICD-10-PCS Coding Guidelines B3.10a states "the body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e.g., thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level."
ICD-10-PCS Coding Guidelines B3.10c states "if an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device."

30. Spinal Fusion of Thoracic and Lumbar Spine
ICD-10-CM/PCS Coding Clinic, First Quarter 2013 Pages: Effective with discharges: March 27, 2013 Question: A patient is diagnosed with T10 chronic burst fracture with subsequent kyphotic collapse resulting in myelopathy and severe myelopathy secondary to spinal cord injury. The procedure is listed as T9, T10, T11 laminectomy, facetectomy, foraminotomy. A transpedicular approach to the T10 vertebral body was used for spinal cord decompression. Instrumentation with pedicle screw and rod construct was placed from T6, T7, T8, T9, T11, T12, L1 and L2. Posterior arthrodesis of T6, T7, T8, T9, T10, T11, T12, L1 and L2 was performed with use of local autograft and allograft. Provider documentation in the body of the operative report indicates arthrodesis, placement of all of the local autograft, as well as crushed cancellous allograft and bone morphogenetic protein (BMP). What are the correct ICD-10-PCS codes for the number of interspaces fused? Answer: Assign the following ICD-10-PCS codes: 0RG7071, Fusion of 2 to 7 thoracic vertebral joints with autologous tissue substitute, posterior approach, posterior column, open approach (fusion of 6 joints between T6 and T12)] The ICD-10-PCS codes for spinal fusion are assigned based on the number of interspaces fused (i.e., 2-3, 4-5, or 6-7) rather site of the fusion. "Thoracic Vertebral Joints, 2 to 7," is the distinct body part value for the 6 thoracic vertebral joints rendered immobile by the spinal fusion. "Posterior Approach, Posterior Column" is the qualifier, since provider documentation indicates transpedicular approach (posterolateral) and posterior arthrodesis (fusion). 0RGA071, Fusion of thoracolumbar vertebral joint with autologous tissue substitute, posterior approach, posterior column, open approach (fusion of one joint between T12 and L1) The "thoracolumbar vertebral joint," is the distinct body part value for the vertebral joint between T12 and L1, rendered immobile by the spinal fusion. "Posterior Approach, Posterior Column" is the qualifier, since provider documentation indicates transpedicular approach (posterolateral) and posterior arthrodesis (fusion). "Autologous tissue substitute" is the device value, since a mixture of autograft, allograft and BMP were used to render all of the joints immobile.

31. Coding Tips for Spinal Fusions
If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier.
Detailed review of Operative Report will be necessary for accurate code assignment.
If another surgical procedure is performed at the same time (another Root Operation or a different Body Part), be sure to code the other component.
Example: Anterior cervical discectomy and fusion
Example: Posterior lumbar fusion using bone graft taken from right iliac crest (hip bone)

32. Discectomy Two root operations: Excision
Resection – complete – radical –
total
Check the description in the operative report for wording which describes how much of the disc is removed

33. Coding Clinics 2nd Q 2014, pages 6-7
A: Discectomy is almost always performed at the same time as spinal fusion surgery. Typically, a fusion involves partial removal of the disc. If the provider performs a discectomy with spinal fusion, it should be coded as excision of disc. If, however, the provider documents “total discectomy” it should be coded as resection. In this case, assign the following ICD-10-PCS codes.
***Discectomy will usually be performed at the same time as insertion of an interbody fusion device***

34. Coding Clinics
2nd Q 2014, pages 6-7 0SG107J fusion of 2 lumbar vertebral joints with autologous tissue substitute, posterior approach, anterior column, open 0SB20ZZ excision of lumbar vertebral disc, open 0QB20ZZ excision of right pelvic bone (iliac crest), open

35. Anterior Cervical Thoracic Fusion with Total Discectomy
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD Pages: 7-8 Effective with discharges: May 26, 2014 Question: A patient is admitted for surgical treatment of herniated nucleus pulposus C7-T1 with impingement on the nerve root, and radiculopathy. She underwent anterior cervical-thoracic spinal fusion, anterior approach, using interbody cage packed with demineralized bone matrix and autograft, and placement of plate and screw instrumentation with total discectomy. What is the correct ICD-10-PCS code for the spinal fusion? Should the complete discectomy be coded separately? Answer: In this case, the provider documented "total discectomy." Therefore it is coded as a resection. Assign ICD-10-PCS procedure codes as follows: 0RG40A0 Fusion of cervicothoracic vertebral joint with interbody fusion device, anterior approach, anterior column, open approach, for fusion C7-T1 0RT50ZZ Resection of cervicothoracic vertebral disc, open approach, for the total discectomy Spinal fusion using an interbody cage containing demineralized bone matrix and autograft is coded to the device "Interbody Fusion Device." Additionally, the fixation instrumentation (i.e., rods, plates, screws, etc.) is included in the fusion root operation, and no additional code is assigned

36. & Fixation Instrumentation
Spinal Fusion
& Fixation Instrumentation

37. What Devices to Code Do Code:
Interbody Fusion Devices: (Cages/Spacers) ***do not code the grafts used to fill the interbody fusion device.
Grafts: Autologous tissue – used in anterior/posterior fusion
Non-autologous tissue - used in anterior/posterior fusion
Synthetic tissue – in anterior/posterior fusion
Do not code the following fixation devices:
**used to perform/reinforce fusion***
Rods plates screws

38. Coding Clinics
3rd Q 2014, page 30 Q: Please clarify whether a separate code is assigned for internal fixation/instrumentation (rods, screws, plates, etc.) used with spinal fusion A: ICD-10-PCS general guideline B3.1b clarifies that components of a procedure specified in the root operation definition and explanation are not coded separately. The explanation for Fusion states “body part is joined together by fixation device, bone graft, or other means.” Therefore, the fixation device is included in the fusion root operation, and no additional code is assigned.

39. Spinal Fusion and Fixation Instrumentation
ICD-10-CM/PCS Coding Clinic, Third Quarter ICD Pages: Effective with discharges: September 15, 2014 Related Information Question: Coding Clinic, First Quarter 2013, pages 29-30, advised to assign code 0RG40A0, for interbody fusion of C7 and T1 with placement of Vectra Synthes plate and screws. Third Quarter 2013, pages 25-26, advised to assign codes 0SG0071 and 0SG00AJ for a 360-degree interbody and autologous bone graft spinal fusion with placement of pedicle screws. Some coders disagree with this advice and feel that the plates and screws used during spinal fusion should be coded separately, since different root operations are utilized. The procedure appears to meet guideline B3.2c (multiple root operations with distinct objectives are performed on the same body part). Please clarify whether a separate code is assigned for internal fixation/instrumentation (rods, screws, plates, etc.) used with spinal fusion. Answer: ICD-10-PCS general guideline B3.1b, clarifies that components of a procedure specified in the root operation definition and explanation are not coded separately. The explanation in the root operation for fusion states "that body part is joined together by fixation device, bone graft, or other means." Therefore, the fixation (rods, plates, screws) is included in the fusion root operation, and no additional code is assigned.

40. Interbody Devices Cages or Spacers (PEEK)
Other devices including the Titan Nanolock
These substances can be used to pack the cages but will not be coded: (Code the cage only)
Demineralized Bone Matrix
Autologous or Non-Autologous Bone Grafts
BMP (Bone Morphogenetic Protein)
Demineralized bone matrix (DBM) is allograft bone that has had the inorganic mineral removed, leaving behind the organic "collagen" matrix. It was first discovered by Marshall Urist in 1965 that the removal of the bone mineral exposes more biologically active bone morphogenetic proteins.[1] These growth factors modulate the differentiation of progenitor cells into osteoprogenitor cells, which are responsible for bone and cartilage formation. As a result of the demineralization process, DBM is more biologically active than undemineralized bone grafts; conversely the mechanical properties are significantly diminished.
Bone morphogenetic proteins (BMPs) are a group of growth factors also known as cytokines and as metabologens.[1] Originally discovered by their ability to induce the formation of bone and cartilage,

41. PEEK Cages/Spacers

42. Substances for Fusions
These substances can be used to fuse the posterior spine:
Autologous Graft from the patient’s own bone
Non-Autologous Tissue Substitute – from a bone bank – cancellous chips
Synthetic – Mastergraft, BMP

43. Coding Guidelines Spinal Fusion Guideline – B3.10C
Code Details – Device (when combinations of devices and materials are used):
If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with Device = Interbody Fusion Device
If bone graft is the only device used to render the joint immobile, the procedure is coded with Device = Nonautologous Tissue Substitute or Autologous Tissue Substitute
If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with Device = Autologous Tissue Substitute
Autologous: If autologous, and either non-autologous or synthetic = autologous
Non-autologous If non-autologous and synthetic = non-autologous
Synthetic

44. Coding Tips for Spinal Fusions
Fixation instrumentation (rods, plates, screws) done along with fusion (interbody device, bone grafts) is included in the Fusion root operation and no additional code is assigned. This is to hold it in place while the fusion heals.
Fixation instrumentation done on other vertebral levels not fused, will be coded using the root operation of Insertion.
Bone morphogenetic protein (BMP) utilized in a fusion is included in the Fusion root operation no additional code is assigned. This is captured in the device character.

45. Titan Nanolock Device Add on Technology codes - This device is used in place of the cages in an anterior fusion Example: XRG1092 Cervical fusion You do not code a separate code for the anterior fusion.
D. New Technology Section
General guidelines D1
Section X codes are standalone codes. They are not supplemental codes. Section X codes fully represent the specific procedure described in the code title, and do not require any additional codes from other sections of ICD-10-PCS. When section X contains a code title which describes a specific new technology procedure, only that X code is reported for the procedure. There is no need to report a broader, non-specific code in another section of ICD-10-PCS.

46. Titan Nanolock Device
We found that the use of the XRG code can group these procedures to the incorrect DRG. When performed with a posterior fusion, they are grouping incorrectly.
CMS is working on resolving the DRG issues associated with coding these devices in Version 35. ~ 3M January 2017

47. Incorrect DRG Grouping with the Titan Nanolock Device

48. What it Should be….

49. Refusions
What to code when a refusion is performed at a different level from previous fusion
Diagnosis: Code reason for refusion
Code Arthrodesis Z98.1
Procedures: Code removal of fixation devices
Code new fusion and other procedures performed
Example: Fx of the pedicle of L5 due to the fixation device (screw)
Previous fusion of L4-5 with rod from L3-5
Removal of rod from L3-L5 – removal of fixation device
Fusion of L5-S1 – New fusion with new rod stated below.
Reinsertion of the rod from L3-S2
Insertion of Rod from L5 to S1 without fusion
Make sure to code removal of any fixation device which is replaced to perform the new fusion

50. Release Spinal Cord Vs. Release of Spinal Nerve

51. Spinal Stenosis
Spinal stenosis is an abnormal narrowing (stenosis) of the spinal canal that may occur in any of the regions of the spine. This narrowing causes a restriction to the spinal canal, resulting in a neurological deficit. Symptoms include pain, numbness, paraesthesia, and loss of motor control.

52. Spinal stenosis/Spinal nerve compression
legacy-images/wu_nerve_compression400-AA.jpg

53. Spinal nerve root decompression
Decompression of nerve root
Spinal nerve root decompression
Laminectomy, laminotomy facetectomy, and/or foraminotomy can done to “Release” the nerve.

54. Example of Release Spinal Nerve
Pre-op diagnosis: spondylosis of L3-4 with radiculopathy Procedure: Laminectomy of L3-4 Description: Decompression foraminotomy and laminectomy were performed with nerve roots decompressed. Correct Code: Release of the lumbar 3-4 nerve root 01NB0ZZ

55. Decompressive Laminectomy Clarification
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD Page: 34 Effective with discharges: July 6, 2015 Question: The patient presents for decompressive lumbar laminectomy. The surgeon performed an open complete decompressive laminectomy of L3-L4, as well as superior partial laminectomy of L5, and inferior partial laminectomy of L2. What is the appropriate root operation, "Excision" or "Release"? How is this surgery coded in ICD-10-PCS? Answer: Decompressive laminectomy is done to release pressure and free up the spinal nerve root. Therefore the appropriate root operation is "Release." Assign the following ICD-10-PCS code 01NB0ZZ Release lumbar nerve, open approach

56. Removal of longitudinal ligament to release the cervical nerve

57. Removal of longitudinal ligament to release the cervical nerve

58. Decompressive Laminectomy/Foraminotomy and Lumbar Discectomy
Question: The patient presents for surgery due to lumbar disc herniation, foraminal stenosis and degenerative scoliosis refractory to conservative treatment. She underwent lateral microdiscectomy, L2-L3 and L3-L4, using intraoperative fluoroscopy. During surgery, disc material displacing the L2-L3 and L3-L4 nerve roots was excised. Foraminotomy was then accomplished by resecting portions of the lamina to decompress the region. Should the decompressive foraminotomy/laminectomy be coded along with the discectomy? Answer: The lumbar disc herniation and foraminal stenosis are separate and distinct diagnoses, and both were surgically treated. Decompressive foraminotomy/laminectomy was done to treat the foraminal stenosis by releasing pressure and freeing up the spinal nerve root, whereas the discectomy was performed to treat the lumbar disc herniation. Each surgery had distinct procedural objectives and should be separately coded. The appropriate root operations are "Excision" and "Release." Assign the following ICD-10-PCS codes:
0SB20ZZ
Excision of lumbar vertebral disc, open approach
01NB0ZZ
Release lumbar nerve, open approach

59. Compression Spinal Cord
Release of spinal cord performed for myelopathy
Release of nerve root performed for radiculopathy
Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression, on the spinal cord and/or nerve roots. Bulging or collapsed disks, thickened joints, loosened ligaments and bony growths can narrow the spinal canal and the spinal nerve openings (foramen), causing irritation.
Symptoms of spinal nerve compression include:
Pain
Numbness
Tingling
Weakness
Unsteadiness
In severe cases, pressure on the spinal nerves can cause paralysis and problems with bladder and/or bowel function.

60. decompression of the foramina
Decompression spinal cord
Central
decompression of the foramina
Laminectomy, laminotomy facetectomy, foraminotomy, and/ or discectomy can be done for the “Release” of the spinal cord for myelopathy.

61. Example of Spinal Cord Release
Patient is a 62 y.o. female with history of progressive myelopathy and evidence of significant C2-C3 stenosis with cord compression and cord signal changes
Pre-Operative Diagnosis: C2-3 stenosis.
Procedure: C2-3 laminectomy.
Operative report description: “Drilled through the bone at the lateral border of the lamina bilaterally from C2 to C3, taking care not to widen the laminectomy so far as to disturb the facets or the stability of the spine at that level.  The spinous processes and lamina were then removed en bloc using an upward motion (away from the spinal canal). After adequate central decompression was achieved”
M Spinal stenosis – cervical region
G Cord compression
00NW0ZZ Release of the cervical spinal cord, open approach.

62. Multiple Decompressive Cervical Laminectomies
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD Pages: Effective with discharges: July 6, 2015 Question: The patient is an 83-year-old male who presented with cervical myelopathy. He elected to proceed with decompressive cervical laminectomy to release the spinal cord. The surgeon performed an open total decompressive laminectomy of C3, C4, C5 and partial decompression of C6. Would it be appropriate to count each vertebra separately, (i.e., C3, C4, C5, and C6) and report four ICD-10-PCS codes? Or, is it appropriate to count each vertebral level decompressed, such as C3-4, C4-5, and C5- C6? ICD-10- PCS Guideline B3.2 states, "During the same operative episode, multiple procedures are coded if: The same root operation is repeated at different body sites that are included in the same body part value." Answer: The laminectomy procedure to release the spinal cord is coded only once because the cervical spinal cord is classified as a single body part. By convention, the vertebral level (C3, C4, and so on) is used to identify a specific area along the spinal cord, but each designation is not considered a separate and distinct body part anatomically. The current version of the ICD-10-PCS guideline B3.2b states, "During the same operative episode, multiple procedures are coded if: The same root operation is repeated at different body parts that are included in the same body part value." The guideline uses two separate and distinct muscles in the upper leg as an example of the correct application of the guideline. The vertebral level designations of the cervical spinal cord do not constitute separate and distinct body parts anatomically, therefore the multiple procedures guideline B3.2b does not apply. Assign the following ICD-10-PCS code: 00NW0ZZ Release cervical spinal cord, open approach Although the ICD-10-PCS “Index entry "Laminectomy," instructs to see Excision, the objective of a decompressive laminectomy is to release pressure and free up the spinal nerve root. Therefore the appropriate root operation is "Release."

63. Compression spinal meninges
Compression of spinal meninges (thecal sac)
Laminectomy, laminotomy facetectomy, and/or foraminotomy
For the
“Release” of spinal meninges due to adhesions or tumors

64. Decompression Spinal Meninges
Meninges are the three membranes that envelop the brain and spinal cord. The meninges are the dura mater, the arachnoid mater, and the pia mater.
Release of spinal (dura) meninges for adhesions or tumors

65. 3M Coding Path

66. Example of Spinal Meninges Release
Preoperative Diagnosis:   recurrent lumbar stenosis L2-3 with neurogenic claudication. Previous L3 - L4 laminectomy.
Postoperative diagnosis: Epidural fibrosis (adhesions)
Procedure description: A complete L2 laminectomy was then performed. The dura was adherent and was dissected free.
Correct codes:
Spinal stenosis L2-L M48.06
Release of the spinal nerves NB0ZZ
Release of the spinal meninges 00NT0ZZ
**ICD-10-CM does not have a code for neurogenic claudication

67. Example of Spinal Meninges Tumor
Pre-operative Diagnosis: L3 intradural extramedullary mass
Post-operative Diagnosis: Schwannona
Operation Performed:  L3 laminectomy, resection of intradural, extramedullary mass
Op note description: L3 laminectomy and Minimal facetectomy was also performed to get good bilateral access to the thecal sac. Incision of the dura with the tumor was found deep to the nerve roots and was elevated out of the thecal sac with removal from the nerve roots.
The correct codes are:
D32.1  Benign neoplasm of the spinal meninges
00B20ZZ  Excision of dura mater, open approach
The laminectomy is not coded as it is the approach to the procedure

68. Example of Synovial Cyst of Spine

69. Artificial Discs
Herniated or damaged discs are replaced with artificial disc devices in either the cervical or lumbar spine. Artificial disc replacement was developed as an alternative to spinal fusion surgery and is designed to reduce or eliminate a patient’s pain level while still maintaining motion throughout the spine.
Root operation Replacement: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part, the removal of the native body part is included in the replacement, so we do not code the removal of the native disc.

70. Additional Procedure Performed During Spinal Surgeries
Procedures Coded:
Nerve monitoring
Computer and/or robotic assisted surgery
Aspiration of bone marrow for graft
Excision of bone for bone graft from another site
Discectomy
Decompression if done at a different level than the fusion
Procedures Not Coded:
Microscopy and Fluoroscopy not coded
Check with your facility. These are the procedures that Providence picks up and those we don’t. Your facility may want to capture microscopy and fluoroscopy.

71. Complications Inadvertent dural tear G97.41
(incidental durotomy, inadvertant entrance into dura)
Symptoms include: postural headache, posterior neck pain or stiffness, nausea, vomiting, photophobia,
diplopia, blurred vision, tinnitus, or vertigo.
Incidental tear of the dural sac and cerebrospinal fluid leak is the most common complication during lumbar spinal surgery. The incidence of dural tear differs depending on the procedure but is much more common in revision procedures, usually because of adhesions in the epidural space and dural scarring and fibrosis. Most dural tears are recognized during the operative procedure and primary repair is performed.
Clinical Documentation Concepts
If the tear is due to a procedure performed during the current admission report 'Accidental puncture or laceration of dura during a procedure' (G97.41).
Always list the dural tear as a secondary diagnosis when it is documented by the physician, even if documented as "incidental". Dural tears are considered clinically significant because of a risk for cerebrospinal fluid leak.

72. Dural Tear Due to Previous Procedure
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD Page: 24 Effective with discharges: December 31, 2014 Question: A patient who was diagnosed with spinal stenosis underwent L2-L3 posterolateral fusion, and repair of midline durotomy. In the body of the report, the provider documented that the durotomy was probably created from previous epidural injections. Is it appropriate to assign code G97.41, Accidental puncture or laceration of dura during a procedure, for the durotomy due to previous epidural injections? Answer: Assign code G96.11, Dural tear, for the durotomy secondary to previous epidural injections. In ICD- 10-CM, "Non-traumatic dural tear" is specifically indexed to code G Also, assign code Y84.8, Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure. In this case, the tear happened before the procedure, so it is not related to the procedure. Code G97.41 would have been assigned if the durotomy had occurred during the current operation.

73. Lipomyelomeningiocele and Tethered Cord
Lipomyelomeningocele: A rare congenital condition where a fatty mass is attached to the spinal cord and protrudes through a defect in the spinal cord. Tethered spinal cord syndrome is a neurological disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal column. Attachments may occur congenitally at the base of the spinal cord (conus medullaris) or they may develop near the site of an injury to the spinal cord.

74. Repair of Lipomyelomeningocele and Tethered Cord
Question:
A 5-week-old baby, who is diagnosed with lipomyelomeningocele and tethered cord, presents for untethering of the cord, excision of the lipoma, which involved the lumbosacral portion of the spinal cord, and microdissection of the spinal cord. At surgery, the area above the lipoma was dissected, and a S1 laminoplasty was performed. After freeing up the dural edges, the lipoma was dissected. Dural patch graft was sewn in using Durepair® to cover the wide opening at the site in which the lipoma was removed. What are the appropriate ICD-10-PCS codes for this procedure?
 Answer:
00NY0ZZ Release lumbar spinal cord, open approach (for the release of tethered cord)
0QQ10ZZ Repair sacrum, open approach (for the S1 laminoplasty)
00BY0ZZ Excision of lumbar spinal cord, open approach (for the excision of the lipoma)
00UT0KZ Supplement spinal meninges with nonautologous tissue substitute, open approach (for
the dural patch graft with Durepair®)
Code update 4th Q 2015, P 39
The Coding Clinic advice is accurate. The body part value "Spinal Meninges" was intentionally chosen. In the Central Nervous System, the body part value dura mater refers exclusively to the dura mater covering the brain. The body part value Spinal Meninges includes all meningeal layers covering the spinal cord. The exclusive use of the dura mater body part value to refer to the brain produces clearer coded data, because it is more important to know whether the procedure was performed on the brain or the spinal cord than it is to know that a procedure was performed on the dura mater meningeal layer. The body part key has been revised to reflect this. 

75. 1st Quarter 2017 Coding Clinic
A staged anterior thoracolumbar fusion of T12-S1 is followed by iliac fixation and posterior instrumented T10-S1 fusion with VIPER®2 System the next day. At the second surgery bone graft was placed for posterior-lateral fusion and titanium rods were connected via pedicle screws from T10-S1 and anchored or fixated with screws to the iliac crest. In addition to coding the posterior-lateral fusion, fixation to the right and left iliac wings (0QH) should be assigned to report fixation that is beyond the fused vertebral levels (sacrum). The sacro-iliac joint is not part of the vertebral joints fused.

76. VERTEBROPLASTY
This procedure is performed when there is a pathological fracture of a vertebrae due to Osteoporosis or cancer or when they are treating a traumatic fracture. This is done for non-displaced fractures. The correct root operation is supplement since the bone is being supplemented with bone cement.

77. Coding Clinic 2Q 2014

78. OP Report Exercises Fusions Release

79. References:
Bartley.com great books online Henry gray ( ). Anatomy of the human body ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 (October 1, September 30, 2017) Jata CDMP Guide Teach me anatomy.info   The free dictionary by Farlex M Coding and reimbursement System Wikipedia.org

80. Questions