Understanding the Intricacies of Spinal Fusion Documentation

Spinal fusions have created confusion for coding, auditing, and clinical documentation integrity (CDI) professionals for many years. Spinal fusion procedures include many different components of the spine and require extensive medical record documentation. A spinal fusion procedure fuses the vertebra using bone grafts, bone substitutes, and interbody fusion devices. The goal of these procedures is typically pain relief after failing treatment with conservative therapy.

Anatomy

The vertebral column of the spine consists of a sequence of vertebrae, each of which is separated and united by an intervertebral disc. It is a flexible column that supports the head, neck, and body and allows for their movements. It also protects the spinal cord, which runs down the back through openings in the vertebrae. The vertebral column is subdivided into five regions. There are eight cervical vertebrae. Superiorly, the C1 vertebra articulates or forms a joint with the occipital condyles of the skull. Inferiorly, C1 articulates with the C2 vertebra, and so on. Below these are the 12 thoracic vertebrae, T1 through T12. The lower back contains the L1 through L5 lumbar vertebrae. The single sacrum, which is also a part of the pelvis, is formed by the fusion of five sacral vertebrae. Similarly, the coccyx, or tailbone, results from the fusion of four small coccygeal vertebrae. The spine is composed of the anterior and posterior columns. The anterior column is composed of the anterior longitudinal ligament, vertebral body, intervertebral disc, annulus fibrosus, and posterior longitudinal ligament. The posterior column includes those spinal structures that are posterior to the posterior longitudinal ligament, such as the pedicles, transverse process, lamina, facets, and spinous process.

Terminology

Combined spinal fusions are often missed by coding professionals, as they struggle with correctly identifying key terms when coding these procedures. Some important key terms associated with spinal fusion procedures are the anterior longitudinal ligament, vertebral body, and posterior longitudinal ligament, which are commonly associated with anterior spinal fusion procedures. Key terms associated with posterior column approaches are procedures performed on pedicles, transverse spinous process, facet joints, and the spinous process. When reviewing the operative report, professionals should be on the lookout for these key terms.

Additionally, it is important to review the medical record documentation and operative report to identify how many incisions were made, what levels of the vertebral column were included in the body of the operative report and procedural documentation, and if they turned the patient and made a new incision. These key terms and documentation “clues” contribute to accurately identifying the correct spinal fusion approach and the type of spinal fusion that is being performed by the provider.

ICD-10-PCS Related Guidelines

According to guideline B3.10a of the ICD-10-PCS Official Guidelines for Coding and Reporting, the body part coded for a spinal fusion procedure is classified by the level of the spine (e.g., thoracic). There are distinct body part values for single vertebral joint and multiple vertebral joints at each spinal level. Coding guideline B3.10b indicates that if multiple vertebral joints are fused, a separate procedure is coded for each vertebral level that used a different device and/or qualifier. Occasionally, instruments called interbody fusion devices are used to stabilize and fuse degenerative disc spaces and to provide a stable segment for fusion and relief of symptoms. These devices are also known as interbody fusion cages, BAK cages, ray-threaded fusion cages, synthetic cages, spacers, or bone dowels. Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value for the procedure is assigned using the following guidelines (B3.10c):

• 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.
• If a bone graft is the only device used to render the joint immobile, the procedure is coded with the device value 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 the device value Autologous Tissue Substitute.

Documentation

It is critical to make sure you are reading and reviewing the detail of the operative report. The devil is in the details when it comes to coding ICD-10-PCS procedures. The provider may reposition the patient or turn the patient over, make a new incision, or the provider will indicate that a fusion is being performed on the annulus fibrosis or vertebral body then will move to the facet joints and transverse process when performing combined anterior-posterior spinal fusions.

These are documentation clues that should be considered when coding a combined anterior/posterior spinal fusion procedure. The key to anterior column approaches is that the incision is made in the neck or the abdomen. During an anterior column fusion, the body (corpus) of adjacent vertebrae are fused (interbody fusion) and can be performed using an anterior, lateral, or posterior technique. Posterior column approaches are identified by incisions made on the patient’s back directly over the vertebrae and include lateral transverse approaches where the incision is made on the patient’s side and the vertebrae are approached through the lamina. A posterior column fusion can be performed using a posterior, posterolateral, or lateral transverse technique and involve fusing of posterior structures of adjacent vertebrae (pedicle, lamina, facet, transverse process, or “gutter” fusion).

Spinal fusion and refusion procedures are coded to the root operation Fusion: “joining together portions of an articular body part rendering the articular body part immobile.” The body part coded for a spinal fusion procedure is classified by the vertebral joint of the spine involved. There are distinct body part values/characters for single vertebral joint and multiple vertebral joints at each spinal level. For example, “lumbar vertebral joint,” (0) “lumbar vertebral joints, two or more,” (1) and “lumbosacral joint” (3). Patients with pseudarthrosis can often function relatively normally. However, if they develop problems such as sharp localized pain and tenderness over the fusion, progression of the deformity or disease, or localized motion in the fusion mass, they may require refusion surgery. Refusion involves the thorough removal of fibrous tissue from the intended fusion area and the addition of a new bone graft. If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier. For example, open fusion of lumbar vertebral joint with synthetic substitute, posterior approach, anterior column (0SG00JJ), and open fusion of lumbar vertebral joint with synthetic substitute, posterior approach, posterior column (0SG00J1), is coded separately because the procedures involve different portions of the column (anterior column versus posterior column). No additional code is assigned for the insertion of fixation devices such as rods, plates, and screws. Insertion of these types of devices is considered an integral component of the root operation Fusion.

Hardware removal from previous spinal fusion and spinal decompressions are additional procedures sometimes performed with spinal fusions. For example, removal of joint internal fixation device from the lumbar vertebral joint should be coded as 0SP004Z. Additionally, decompression of the lumbar plexus nerve should be coded as 01N90ZZ, Key terms found within the documentation could be release and decompressions performed on spinal nerve roots or releasing the spinal cord. Removal of herniated or damaged vertebral disc documentation would include removing a portion of the vertebral disc, including free fragments or total removal of the vertebral disc. Intraoperative nerve monitoring (also known as IOM) can be coded when the operative detail supports the patient’s neurological functions being monitored while under anesthesia during the spinal fusion procedure.

Some commons terms that will help you identify the IOM are EMG, SSEP, MEP, and Sentio MMG. AHA Coding Clinic, First Quarter 2015, notes that Sentio MMG is like an EMG with the sensors being placed on the skin. There is variability where the probe is placed, and the measuring device is external. In the case where the Sentio MMG is used to ensure the protection of nerve roots, monitoring is the procedure performed, and the external approach should be used when sensors are placed on the skin. The IOM procedure code can be reported if the facility chooses to report this code as an additional procedure. The synchronous harvesting of bone graft (e.g., iliac crest) from a separate incision that is to be used in a different part of the body (e.g., for spinal fusion) is reported separately (root operation “Excision”). However, when coding a fusion in ICD-10-PCS, locally harvested tissue (e.g., bone marrow harvested from the femur and used as a stem cell autograft) is not coded separately. If bone morphogenetic protein (BMP), a genetically engineered protein, is inserted to help create a bone graft substitute, it is identified with the device character in the fusion code. Reporting a code for placement of BMP is optional, and facilities may code it if desired. When an open approach is used, assign code 3E0U0GB, Introduction of recombinant bone morphogenetic protein into joints, open approach.

Spinal fusions can be tricky and complex depending upon the provider’s documentation in the medical record. However, professionals can reduce the spinal fusion confusion by breaking these procedures into the position of the patient, what anatomical sites were fused, if the provider documented any additional procedures performed through a separate incision or with a different device, and if the documentation supported coding anterior, posterior, or both. It is imperative to remember the key terms and clues provided because they can serve as a tool that can be leveraged to identify those common missed revenue opportunities.

References

• Anatomy of the Lumbar Spine [Digital image]. (n.d.). Retrieved March 8, 2021, from https://images.squarespace-cdn.com/content
• ICD-10-PCS Official Coding Guidelines for Coding and Reporting, 2021
• Intervertebral disc [Digital image]. (n.d.). Retrieved March 8, 2021, from https://openstax.org/resources/4b8ca232c0ac2d22d1ba1be3b8ce86ea2975f5ea
• AHA Coding Clinic®, Second Quarter 2014, pgs.: 6-7.
• AHA Coding Clinic®, Third Quarter 2013, pg. 25.
• AHA Coding Clinic®, First Quarter 2017, pg. 21.
• AHA Coding Clinic®, Second Quarter 2016, pgs. 6-7, 16.
• AHA Coding Clinic®, First Quarter 2015, pg. 26.
• AHA Coding Clinic®, Third Quarter 2014, page 24.
• AHA Coding Clinic®, Fourth Quarter 2015, page 39.
• AHA ICD-10-CM and ICD-10-PCS Coding Handbook.

Tina Bruce (brucet@sanjuancollege.edu) is assistant professor at San Juan College.