tci Part B Insider - 2013 Issue 18

Part B Coding Coach: Apply This Expert Advice For Spinal Instrumentation Claims Success

Location and levels lead you to the correct code. When reporting spinal instrumentation, the key is to confirm the segments where the instrumentation was done and to verify whether your surgeon was replacing or removing the instrumentation. 1. Verify the Location You need to determine from the op note whether your surgeon performed anterior or posterior instrumentation. If this isn’t clear, check with your surgeon. "Documenting the approach (anterior, posterior, direct lateral, extreme lateral) is something that spine surgeons do almost unfailingly," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey...

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