The patient is an 11-year-old male with neuromuscular thoracolumbar scoliosis, who is status post insertion of growing rods. He had previously undergone lengthening of the growing rods on two occasions, and now presents for bilateral open lengthening of the growing rods. The surgeon loosened the set screws and using a rod holder and distractor, both sides of the thoracic spine were lengthened approximately 1 cm.
We are considering several possibilities for the principal diagnosis code: Z45.89, Encounter for adjustment and management of other implanted devices; Z47.82, Encounter for orthopedic aftercare following scoliosis surgery; and Z46.89, Encounter for fitting and adjustment of other specified devices. What are the appropriate diagnosis and procedure codes?
Assign code Z45.89, Encounter for adjustment and management of other implanted devices, as the principal diagnosis. Code M41.45, Neuromuscular scoliosis, thoracolumbar region, should be assigned as an additional diagnosis. If documented, assign also a code for the underlying condition responsible for the neuromuscular scoliosis.
This procedure is consistent with the ICD-10-PCS definition of the root operation “Revision.” The child has grown, the device is now malpositioned, and needs to be moved because its functioning is suboptimal. Assign the following ICD-10-PCS code for the bilateral open lengthening of the growing rods:0PW404Z Revision of internal fixation device in thoracic vertebra, open approach