AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 2; Ask the Editor
Dorsal Root Entry Zone Procedure
A patient with left cervical pain due to dorsal root avulsion underwent surgical treatment. Following exposure of the C6-T2 spinous processes, a laminectomy was performed and a microscope was used for microscopic dissection. A microscope was then used to open the arachnoid, and dorsal root entry zone (DREZ) lesions were made between the T1 and C7 rootlets. What is the appropriate procedure code for this DREZ procedure? ...
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Article Overview
This article explains how to think about coding a dorsal root entry zone procedure performed after exposure of the cervical and upper thoracic spine. It is aimed at medical coders, CDI professionals, auditors, and other revenue cycle staff who need to recognize the procedure context and understand the ICD-10-PCS assignment discussed in the article.
Why This Topic Matters
Dorsal root entry zone procedures can involve anatomy across more than one spinal region, so accurate procedure identification and code-set selection matter for compliant inpatient coding and reporting.
What You Will Learn
- How a dorsal root entry zone procedure is described in operative language
- How the article frames the associated ICD-10-PCS coding
- How cervical and thoracic spinal cord involvement is represented in inpatient procedure coding context
- How the procedure context affects code selection at a high level
Who Should Read This
- Medical coders
- Coding auditors
- CDI specialists
- Revenue cycle staff
- Compliance professionals
Codes Discussed
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