The health record documentation states that the patient underwent laminectomy C3 through C7, decompression of the spinal cord, placement of posterior instrumentation and spinal fusion, due to cervical spondylosis. After decompression of the spinal cord, lateral mass screws were placed from C3-C6 bilaterally with connecting rods. Would placement of instrumentation be coded as a pedicle based stabilization device? What device value is assigned for the spinal fusion? Would the decompression of the spinal cord be coded separately or is it considered inherent to the total surgery?
In this case, a spinal fusion was not carried out. There was no documentation of bone graft or a bone graft substitute being utilized; only spinal cord decompression and insertion of rods and screws (instrumentation) were accomplished. Instrumentation alone does not constitute a spinal fusion. Spinal fusion involves the use of bone graft or bone graft substitute, which can be done with or without instrumentation. Further, the insertion of rods and screws is not the same as the placement of a pedicle based stabilization device. The device value “Spinal stabilization device, pedicle based” is not used, because that device value is only used for specific stabilization systems.
The root operation “Release” is coded separately when decompression is documented, and there is a distinct surgical objective, not just incidental removal of the lamina to reach the site of the procedure. Assign the following procedure codes:
0RH104Z - Insertion of internal fixation device into cervical vertebral joint, open approach
00NW0ZZ - Release cervical spinal cord, open approach