AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2013 Issue 1; Ask the Editor - ICD-10-CM/PCS Coding Questions
Spinal Fusion of Thoracic and Lumbar Vertebrae
A patient is diagnosed with T10 chronic burst fracture with subsequent kyphotic collapse resulting in myelopathy and severe myelopathy secondary to spinal cord injury. The procedure is listed as T9, T10, T11 laminectomy, facetectomy, foraminotomy. A transpedicular approach to the T10 vertebral body was used for spinal cord decompression. Instrumentation with pedicle screw and rod construct was placed from T6, T7, T8, T9, T11, T12, L1 and L2. Posterior arthrodesis of T6, T7, T8, T9, T10, T11, T12, L1 and L2 was performed with use of local autograft and allograft. Provider documentation in the body of the operative report indicates arthrodesis, placement of all of the local autograft, as well as crushed cancellous allograft and bone morphogenetic protein (BMP). What are the correct ICD-10-PCS codes for the number of interspaces fused? ...
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Article Overview
This premium article explains a spinal fusion case involving the thoracic and lumbar spine and discusses how the operative record is interpreted for ICD-10-PCS coding. It is aimed at inpatient coders, coding educators, CDI staff, and auditors who work with complex spine surgery documentation. The article centers on the clinical and operative details that affect selection of the correct spinal fusion code based on the number of interspaces fused.
Why This Topic Matters
Spine fusion cases often require careful review of operative reports to determine the correct ICD-10-PCS assignment. This article is relevant because it addresses documentation elements that influence how the fusion level is counted and reported.
What You Will Learn
- How a thoracic and lumbar fusion case is described in operative documentation
- Which documentation elements are relevant when determining fusion extent
- How this type of case relates to ICD-10-PCS spinal fusion reporting
- What information in the operative report supports code assignment review
Who Should Read This
- Inpatient coders
- Coding auditors
- Clinical documentation improvement specialists
- Coding educators
- Revenue integrity staff
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