Our recent review at a healthcare provider revealed some coding mistakes in spinal fusion surgeries. These were particularly in cases where a patient had a two-part surgery: first an anterior spinal fusion and then, two days later, a posterior fusion. Here's a summary of our advice to improve accuracy in coding these procedures.
In many surgeries we looked at, surgeons made an incision from the front (anterior) and worked their way to the spine. Sometimes they used a side approach (OLIF) and often, they used robotic technology and special navigation systems. It's important that these details are recorded correctly on the day of surgery.
We noticed two surgeons usually participated in the surgery. One made the incision and exposed the spine, and the other performed the spinal work, like removing the disc and fusing the bones. Coders should make sure to read both surgeons' reports to capture all the details.
For the follow-up surgery through the back (posterior), the same attention to detail in coding applies, especially if navigation systems were used again.
Coders need to know if the entire disc was taken out or just part of it. This changes the code: a complete removal is a "Resection," while a partial one is an "Excision." This must be clear from the medical records.
Sometimes the surgery also involves relieving pressure on the nerves or spinal cord. The coding should clearly state where this decompression happened, and it should only be marked once for each specific area. Even if the surgeon removes bone or disc material, the goal is decompression, and that’s what the code should reflect. If the decompression is done on both the nerve roots AND spinal cord, both codes should be reported.
Navigation systems help the surgeon by providing a map of the patient's anatomy during surgery. When they are used with a CT scan, the coding should reflect that. Coders must make sure they're not using the default code that means "no specific technology was used."
Robotic assistance, like with the Mazor Stealth system, is used in some anterior fusions. It's important not to mistake the use of a robot as a sign of a less invasive surgery. The coding should reflect the actual surgical technique that was used.
Bone Morphogenetic Protein (BMP), often seen as INFUSE in records, is used to promote bone growth and is usually noted in coding. However, bone putty is different and isn't coded separately when used with other materials.
We hope these tips will make spinal fusion coding clearer and more straightforward. Remember, the key to correct coding is a complete and accurate review of all the surgery details.
Spinal Fusion Coding is complex due to the variety of conditions requiring fusion and the intricacies of ICD-10-PCS code selection. The training plan addresses this by educating coders on the structural and functional aspects of the spine, such as its role in supporting the upper body and enabling movement while protecting the spinal cord. Coders learn to accurately report both the diagnoses and procedures associated with spinal surgeries, supported by detailed reviews of operative reports and relevant Coding Clinics and CPT Assistant articles. The plan emphasizes the importance of understanding the spinal structure, the reasons behind spinal fusion, and the procedural details, ultimately enhancing coding accuracy, procedural knowledge, and diagnosis precision through comprehensive training and updated clinical guidelines. View Spinal Fusion Coding Training Plan »
HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for over 30 years—offers a comprehensive online education platform for medical coders. With a catalog of over 250 medical coding courses accepted by the American Health Information Management Association (AHIMA) for Continuing Education Units (CEUs) and a selection accredited by the American Academy of Professional Coders (AAPC), HIAlearn caters to both beginners and experienced medical coders seeking to enhance their skills. The platform provides an array of training plans tailored to meet individual learning needs, from mastering challenging coding procedures to understanding broad conceptual frameworks within the coding world. Courses are available across various coding types including CPT, E/M, ICD-10-CM, ICD-10-PCS, and are designed to cater to different coder levels and coding specialties such as inpatient, outpatient, profee, and CDI. Additionally, HIAlearn offers a Coding Updates bundle to ensure coders are up-to-date with the annual changes in ICD-10-CM, ICD-10-PCS, CPT, and IPPS. Beyond individual learning, HIAlearn supports organizations with group discounts, promoting enhanced coding accuracy, efficiency, and compliance across teams. With over 1,600 users already part of the HIAlearn community, the platform stands as a testament to its commitment to providing quality education and support for medical coders nationwide.The information contained in this blog post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.