This patient presented with spinal stenosis and progressive neurogenic claudication at L4-5 and L5-S1. The patient underwent microsurgical decompression laminectomy, placement of Dynesys® dynamic stabilization device with lateral spinal fusion, and harvesting of autologous bone marrow. The bone marrow was aspirated and mixed with CopiOsâ„¢ bone void filler. This matrix was then mixed with morselized bone, and used in the lateral mass fusion, L4-L5 and L5-S1. How should this case be coded?
Assign code 724.03, Spinal stenosis, Other than cervical, Lumbar region, with neurogenic claudication, as the principal diagnosis. Assign codes 84.82, Insertion or replacement of pedicle-based dynamic stabilization device(s), for the insertion of the Dynesys® stabilization device. Since a fusion was done, assign code 81.07, Lumbar and lumbosacral fusion, Lateral transverse process, for the lateral mass fusion. Additionally, assign codes 03.09, Other exploration and decompression of spinal canal, for the decompressive laminectomy, 81.62, Fusion or refusion of 2-3 vertebrae, to indicate the total number of vertebrae fused, and 41.98, Other operations on bone marrow, for the aspiration of autologous bone marrow used in the lateral mass spinal fusion. Studies have indicated that spinal fusion using cell matrix composites enriched in bone marrow-derived cells can improve the outcome of bone grafting.
Code 41.91, Aspiration of bone marrow from donor for transplant, is not appropriate since this was not a bone marrow transplant.