AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2015 Issue 2; Ask the Editor

Multiple Decompressive Cervical Laminectomies

The patient is an 83-year-old male who presented with cervical myelopathy. He elected to proceed with decompressive cervical laminectomy to release the spinal cord. The surgeon performed an open total decompressive laminectomy of C3, C4, C5 and partial decompression of C6. Would it be appropriate to count each vertebra separately, (i.e., C3, C4, C5, and C6) and report four ICD-10-PCS codes? Or, is it appropriate to count each vertebral level decompressed, such as C3-4, C4-5, and C5-C6? ICD-10- PCS Guideline B3.2 states, “During the same operative episode, multiple procedures are coded if:  The same root operation is repeated at different body sites that are included in the same body part value.” ...

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