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AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 1; Ask the Editor

Placement of Interspinous Distraction Device (Spacer) for Decompression

A patient, who has Grade III L5/S1 anterior spondylolisthesis with right leg sciatica, presents for surgical treatment consisting of laminectomy, posterior lumbar decompression, non-segmental posterior spinal instrumentation and posterior/posterolateral spinal fusion with posterolateral placement of local bone autograft (L5/S1). Surgery revealed the L5 and S1 nerve roots to have residual proximal-to-distal stenosis, and a decision was made to perform an indirect decompression. A distraction spacer was placed within the disc space to maintain the distraction. A repeat interrogation of the neuroforamenae revealed the L5 and S1 nerve roots to be well decompressed and free of residual compression. After completion of the decompression, rods were placed and the spinal deformity was corrected. Is the placement of the distraction device considered integral to the posterior/posterolateral spinal fusion? What is the correct ICD-10-PCS code for placement of an interspinous distraction device for “decompression?” ...

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