The Central Office on ICD-9-CM has recently received several questions related to the coding of the newer minimally invasive spinal fusions: the extreme lateral interbody fusion (XLIF®), the direct lateral interbody fusion (DLIF) and the axial lumbar interbody fusion (AxiaLIF®).
The extreme lateral interbody fusion (XLIF®) is an innovative less invasive spinal surgery of the anterior column. The XLIF® is one of several options for spinal surgery and treats specific problems, such as lumbar degenerative disc disease, spondylolisthesis, and scoliosis as well as recurrent lumbar disc displacement and lumbar spinal stenosis. However, the procedure may not be appropriate for some conditions at the lowest lumbar levels (e.g., L4-L5 or L5-S1). The fusion may be accomplished either percutaneously or via a circular tube retractor through a lateral approach. Small incisions are made in the lateral flank region with little disruption of the surrounding tissue. The disc is removed and a polyethylene (PEEK) spacer is inserted into the disc space. The position and placement of the spacer is monitored fluoroscopically along with neurophysiologic monitoring.
The direct lateral lumbar interbody fusion (DLIF) is a minimally invasive alternative to conventional spinal fusion. The DLIF is performed through a lateral approach, which allows for limited soft tissue disruption. An allograft is implanted laterally through the right or left side of the disc space. The procedure can only be performed at L4-L5 or at higher levels and requires dissection through the psoas muscle. Following discectomy, the allograft is placed and instrumentation consisting of either titanium plates or posterior pedicle screws is then inserted.
The axial lumbar interbody fusion (AxiaLIF®) is a percutaneous fusion of the anterior column at L5-S1. The AxiaLIF® system includes titanium implantable devices and instrumentation made of biocompatible materials. In the AxiaLIF®, the lumbar spine is accessed through a percutaneous incision next to the sacral bone. This approach alleviates the need for the surgeon to incise muscles and ligaments. The disc is removed and the fusion is accomplished by inserting bone growth material. This material stimulates bone growth over time in order to fuse and stabilize the spine. An AxiaLIF® 360Âº refers to the combination of an AxiaLIF® procedure of the anterior
An "interbody fusion' is a fusion of the anterior column of the spine. In traditional spinal fusion surgery, the anterior column may be fused using an anterior, lateral, posterior, or a combined (anterolateral) (posterolateral) technique. A posterior column fusion can be performed using a posterior or lateral transverse technique. The technique utilized and the column being fused may affect correct code assignment. The DLIF and XLIF® are accomplished via a lateral approach, which is more towards the back (posterior) than the front (anterior). The AxiaLIF® is performed percutaneously close to the sacrum. Therefore use code 81.08, Lumbar and lumbosacral fusion, posterior technique, for these newer techniques.
Currently, the ICD-9-CM Volume 3, Procedure Index does not contain clear, specific entries for these lateral and percutaneous techniques. A proposal will be presented at the September 2009 Coordination and Maintenance (C&M) Committee meeting to update the current index and tabular to help clarify and assist the coder with consistent and accurate reporting of these newer procedures.
The following questions and answers have been developed to provide guidance on how to code these procedures.
The patient was admitted for surgical treatment of degenerative disc disease at L5-S1 and underwent AxiaLIF® procedure. The surgery involved disc excision, axial lumbar interbody fusion with screw fixation at L5-S1, posterior column fusion (percutaneous facet fusion) with bone morphogenetic protein (BMP), percutaneous pedicle screw fixation at L5-S1 using the Sexton system and NIMS monitoring. How should this surgery be coded? There is some confusion about whether this should be coded as a 360 degree spinal fusion and whether a code should be assigned for the pedicle screw instrumentation.
Assign code 80.51, Excision of intervertebral disc; code 81.08, Lumbar and lumbosacral fusion, posterior technique, for the AxiaLIF® procedure of the anterior column; code 81.07, Lumbar and lumbosacral fusion, lateral transverse process technique for the posterior column fusion; and code 84.52, Insertion of recombinant bone morphogenetic protein. Code 81.62, Fusion or refusion of 2-3 vertebrae, and code 00.94, Intra-operative neurophysiologic monitoring, should also be assigned. It is inappropriate to assign a code for the instrumentation. The instructional note at category 81.0 indicates that internal fixation is included with the spinal fusion code.
The patient had an extreme lateral interbody fusion (XLIF®), L3-4 with CoRoent XL interbody implant, bone morphogenetic protein, discectomy, Vitoss, and direct lateral segmental plate fixation, L3-4. What are the appropriate codes for these procedures?
Assign code 81.08, Lumbar and lumbosacral fusion, posterior technique, for the XLIF®. Code 80.51, Excision of intervertebral disc; code 84.51, Insertion of interbody fusion device; code 84.52, Insertion of recombinant bone morphogenetic protein; and code 81.62, Fusion or refusion of 2-3 vertebrae, should be assigned for the other procedures.
A patient is diagnosed with lumbar stenosis and segment degeneration at L2-L3. The procedure is listed as: direct lateral lumbar interbody fusion (DLIF) through a left sided approach, laminectomy L2-L3, posterior spinal fusion L2-L3, and instrumentation L2-L3. Provider documentation indicates that the patient was positioned left side up and an incision was made lateral to the disk space of L2-L3. An annulotomy was performed and the disk space was cleaned out. Infuse was put into the cages which was impacted into the disk space. The soft tissue was closed in layers and the patient was then turned to a prone position. Incisions were made down to the spinous process. Two spinous processes were taken down and a laminectomy of L2-L3 was performed. Medial facetectomy was also done and good decompression was noted. Screws were placed, Infuse was packed into the facet joint and a small amount of local autograft bone was applied dorsal to the Infuse. What is the correct code for the DLIF portion of the procedure?