Watching a ballerina dance across the stage or a football player zigzagging down the football field illustrates the amazing motion our spines provide us. A healthy spine allows us flexibility, motion and stability to stand or walk. When our spine or backbone is compromised by injury or disease it can affect every part of our life. Spinal injuries, degenerative spinal conditions and congenital spinal deformities cause pain and interfere with a person’s quality of life. After more conservative medical interventions have failed, many spinal problems are resolved with surgical fusion of one or more vertebras in the back.
Coding spinal fusions with ICD-9-CM Vol. 3 codes on the CCS exam will require knowledge about spinal anatomy, anatomic planes and the operative procedures. Success in coding these procedures will also require taking time to study and practice coding spinal fusions. Fusion codes have adjunct procedure codes, which are used in conjunction with the fusion codes to provide additional information about the procedure. We will discuss only fusion procedures in this article.
Conditions where spinal fusion maybe considered: Degenerative disc disease, spinal disc herniation, spinal tumor, vertebral fracture, scoliosis, kyphosis, spondylolisthesis and/or spondylosis.
Anatomy of the Spine
The spine (backbone) is made up of a chain of 33 vertebrae with intervertebral discs of fibrocartilage between most of them. The vertebrae are classified as amphiarthroses joints, because they are slightly movable.
We are including a picture of the spinal column for reference with this article. Starting with vertebrae at the top of the spine, we have the cervical (C1-C7) vertebrae, followed by the thoracic vertebra (T1-T12) and finally the lumbosacral area (L1-S1). It is very important to review and know the locations of each of these vertebrae to code spinal fusions accurately.
The shape and structure of the vertebra are very different in the anterior portion vs. the posterior portion. The anterior portion of the vertebra is round and smooth. Contrarily, the posterior (back) of the vertebra has three boney protrusions: in the middle is a spinous process (that resembles a dorsal fin), attached to it is the lamina; bilaterally the lamina are surrounded by pedicle and facet joints. Between each vertebra is an intervertebral disc. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae, and acts as a ligament to hold the vertebrae together. Lastly and, most important, at the center of the vertebra is the spinal cord.
Anterior, Anterolateral, Posterior, Posterolateral, Lumbar and Lumbosacral
Knowledge of the anatomical planes of the body area is required for assignment of the correct codes. Anterior is the front of the body and is included in the ventral cavity. Posterior is the back of our body and is included in the dorsal cavity. These two terms, anterior and posterior, will help us determine the site and approach of spinal fusion procedures. Dorso (back) and lateral (side) will be included in some operative report details, and the ICD-9-CM volume 3 codes contain these terms.
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Types of Spinal Fusions |
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Arthrodesis (fusion) 81.00-81.08 |
Refusion 81.30-81.39 |
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Arthrodesis means fusion of bone. Spinal fusion is immobilizing the vertebrae by fusing one or more to each other to stop them from moving. |
Pseudarthrosis is referred to a failed fusion, nonunion, and requires refusion of the vertebrae. |
Spinal Fusion Procedure
A spinal fusion procedure includes making an incision in the skin at the site of the injured or diseased vertebrae. The spine can be approached surgically from the front (anterior), back (posterior) or laterally (side) to fuse the vertebrae. It is fairly common to use bone grafts, harvested from the patient’s pelvis (iliac crest) to pack in and around the vertebrae during the fusion. The bone graft is fixated to the vertebrae to help the bones heal together. Metal rods and metal screws are often used to lock the two vertebras together to prevent movement. A metal rod or cage can also be part of the procedure of fusing vertebrae. There are many different ways that vertebrae can be surgically fused. Most of the spinal fusions involve some kind of removal of lamina or discectomy, drilling of bone, harvesting of bone grafts and fixation with insertion of a spinal fusion device.
Coding spinal fusion procedures on the CCS exam will also require excellent knowledge of the detailed steps involved in coding spinal fusions.
How to Code Spinal Fusions
Always consult your ICD-9-CM Volume 3 Index first to locate the correct code or code range for coding inpatient surgical procedures. We have two places to review codes in the index: Arthrodesis and Fusion.
The main term, Fusion, spinal, will give us the complete code range for coding any and all spinal fusions. Refusion is in the index, and it is also found under main term “Fusion, spine, vertebrae, for pseudarthrosis.”
Next, read the ICD-9-CM Code Book, Volume 3, instructional notes and INCLUDES note:
There are several questions the procedural documentation should be able to answer. There are several steps you will have to complete to accurately code spinal procedures. This information should be in the operative report signed by the physician. If any of the following information is not answered in the operative report, query the physician.
Steps:
1. Read the operative report in its entirety.
2. Identify if the operation is a Spinal Fusion (codes 81.00-81.08) or Refusion of the spine (81.30-81.39).
3. Determine the level of spine fused (Cervical, Thoracic, Lumbar, Lumbar Sacral).
4. Identify where the site of the procedure was performed on the spinal column:
- Anterior (front) of the spinal column
- Posterior (back) of the spinal column
5. Identify the technique/approach used to access the spinal column site:
- Anterior, Posterior, Anterolateral, Posterolateral or Anterior/lateral/transverse
6. Was there a bone graft taken (locally) from the patient at the same operative encounter (rib, ilium or vertebral)?
7. Identify the number of vertebra being fused and the number of each of the vertebrae:
- One level fusion (fuses two vertebrae) L1-L2 codes to 81.62 Two level fusion (fuses three vertebrae) L1-L3 codes to 81.62 Third level fusion (fuses four or more) C3-C6 codes to 81.63
8. Was there insertion of an interbody spinal fusion device (84.51)?
The tabular code descriptors include the vertebral location, the area of the column and the technique (approach):
Example: 81.08 Lumbar and lumbosacral fusion of the anterior column, posterior technique.
Read the code and operative report very carefully. As we can see in the code 81.08 above, the fusion was on the “anterior column,” but the approach or technique was from the back or posterior. Next, we need to move on to adding adjunct codes to further describe the procedure. Were there any bone grafts? How many vertebras were fused? Were spinal devices inserted?
The Table below could be used to make sure you abstract from the operative report the correct information for coding spinal fusions:
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Abstract from Op Report |
Required to Code Fusions |
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Choose Code Range: |
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Choose level: |
Vertebrae level:
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Column treated: |
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Technique-Approach: |
Anterior
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Posterior
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Adjunct Codes |
Code Also: |
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Graft from pelvis or laminectomy for fusion? |
Bone graft from patient (e.g. ilium, rib, pelvic bone graft, laminectomy) 77.70 to 77.79 Excision Local of bone for graft |
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Number of fused vertebrae |
# Number of vertebrae fused
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A device? |
84.51 Insertion of interbody spinal fusion device: Insertion of: cages, interbody fusion cage, synthetic cages or spacers |
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Bone morphogenetic? |
84.52 Insertion of recombinant bone morphogenetic protein |
Coding spinal fusions is complicated and there are usually several additional procedures accomplished during the same operative episode. But if we break down the codes that are required, and identify the main objective of the operation, we can successfully code these operations.
The image to the left provides an illustration of the complexity of spinal fusion procedures. There are many steps to the procedure, which makes interpreting the operative report and applying the codes challenging.
For the CCS exam preparation, you must become familiar with all the terms defined in this article. Review the anatomy of the spine and the different terms for parts of the vertebra. Also familiarize yourself with the different anatomical planes of the body. Practice and read the coding sections under category 81.0- and 81.3- completely. Knowledge about spinal fusion terms, anatomy, operative procedures and the code book will provide you with an edge when you take your exam. Coding spinal fusions is manageable if you prepare and study the steps necessary to correctly abstract from the medical documentation.
Take the quiz and test your knowledge on page 2.
Questions
1. Spinal fusion codes (81.00-81.08) and refusion (pseudarthrosis) codes (81.30-81.39) both have “code also any” adjunct codes. What are the adjunct codes that they both share (code also any)?
a. Interbody spinal fusion device (84.51)
b. Synchronous excision of locally harvested bone for graft (77.70-77.79)
c. Recombinant bone morphogenetic protein (84.52)
d. Total number of vertebrae fused (81.62-81.64)
e. All of the above
2. What are the codes for a spinal fusion of the L4-L5 and L5-S1 (lumbosacral) vertebrae, performed on the posterior column, with a posterior technique?
3. A patient with severe cervical spine stenosis underwent anterior column, anterior approach and fusion of C3-C6 vertebrae. How should this be coded?
4. What are the codes for a bilateral laminectomy (bone graft), L1-L2, with posterior technique, interbody fusion (anterior column) with implantation of Titanium Ray cages? The fusion uses locally harvested autograft arthrodesis.
Answers
1) e. All of the above
2) 81.07; 81.62
3) 81.02; 81.63
4) 81.08, 81.62, 84.51 & 77.79
Lindsey Asmus, RHIT CCS CCS-P CCDS, is an approved AHIMA ICD 10 CM/PCS trainer and the content editor manager for Precyse University (www.Precyseuniversity.com). She has more than nine years of experience coding and auditing in both inpatient and outpatient settings. She taught as an adjunct instructor at an AHIMA-approved college in the Health Information Technology associate programs. She is currently a co-facilitator of the Florida CSA and Studying for the CCS, community of practice (COP) for AHIMA members.
