The patient, who has been diagnosed with cervical spinal stenosis, myelopathy and radiculopathy, presents for surgical treatment consisting of percutaneous posterior placement of DTRAX interfacet stabilization device with bone graft (C3 through C6). Under fluoroscopic guidance, procedures performed included posterior laminectomy for decompression and partial facetectomy. Harvesting of bone graft from the left iliac crest was accomplished via an open approach. Would the placement of the DTRAX interfacet stabilization device be coded using the root operation “Insertion” or “Fusion?” What are the correct ICD-10-PCS code assignments?
Assign the following procedure codes:
0RG2371 Fusion of two or more cervical vertebral joints with autologous tissue substitute, posterior approach, posterior column, percutaneous approach, for the cervical spinal fusion
00NW3ZZ Release cervical spinal cord, percutaneous approach, for the cervical decompression
0QB30ZZ Excision of left pelvic bone, open approach, for the harvesting of the iliac crest bone graft
The DTRAX Spinal System is a set of instruments intended and indicated for access and preparation of a spinal joint to aid in fusion. When assigning ICD-10-PCS codes for procedures using DTRAX spinal instruments, coding professionals should code the procedure based on what was done, rather than the device used. In this case, a posterior fusion between the facet (interfacet) was done, not an interbody fusion. If the documentation is unclear, query the physician for clarification.