Spinal Fusion

Coding Spinal Fusion: PCS vs. CPT

C. Matheson, RHIA, CCS MRA Leave a Comment

Spinal Fusion

Coding Spinal Fusion: PCS vs. CPT

When circumstances call for coding the same procedure in both CPT and ICD-10-PCS, a number of variables can make it challenging to get the coding right. For instance, the rules and guidelines that dictate whether an accessory procedure is integral to the primary procedure or separately reportable vary with the type of codes you are using.

Spinal fusion coding is one area where it’s difficult to get the coding of the procedure straight in either CPT or ICD-10-PCS, let alone knowing how to report these procedures correctly in both code sets. To help point you in the right direction when coding spinal fusion, the information that follows provides a high level overview of some foundational material related to spinal fusion procedures and a high level comparison of the codes that may or may not be assigned when reporting spinal fusion in either ICD-10-PCS or CPT.

Associated Diagnoses

Spinal fusion procedures are performed to treat a variety of conditions. It’s common to see the diagnoses in the list below as the pre/post-operative diagnosis for a spinal fusion procedure.

• Degenerative disk disease

• Spinal stenosis

• Scoliosis

• Spondylosis/spondylolisthesis

• Fracture, tumor or infection

Purpose/Definition

The purpose of a spinal fusion, which may also be referred to as an arthrodesis, is for new bone to grow into the spaces between and around the vertebrae to immobilize the joint(s) at the level of the fusion. Achieving fusion of the joints requires the use of bone graft or bone graft substitute. Although accompanying instrumentation or fixation devices may be used in spinal fusion procedures, their use is not technically required for the procedure to be considered a fusion, as spinal fusion may be achieved via the placement of bone graft or bone graft substitute alone.

Documentation

Some of the biggest differences between CPT and ICD-10-PCS code assignment for spinal fusion are related to coding for the accessory procedures that may or may not be separately reportable depending on the code set you are using. Determining if these procedures should be coded and assigning the correct codes when needed will depend on a careful and thorough review of the operative report documentation to identify critical details that impact code assignment.

Let’s take a look at some of these accessory procedures to learn if they should be reported when working in a specific code set and if so, what kind of details need to found in the operative report to allow complete and correct coding.

Discectomy

ICD-10-PCS – Discectomy is coded separately in ICD-10-PCS. For total discectomy, the root operation assigned is Resection. For a partial discectomy, the root operation assigned is Excision. See AHA Coding Clinic, 2nd Qtr. 2014, pages 6-7.

CPT – In CPT, discectomy solely to prepare the vertebra for fusion is included in the description of the spinal fusion code and is therefore considered integral to the fusion procedure. Discectomy in the same interspace where the fusion it taking place, and which requires additional work for the purpose of completing spinal decompression, is separately reportable. See AMA CPT Assistant, January 2001, pg. 12, 13.

Bone Graft

ICD-10-PCS – In ICD-10-PCS the use bone graft is indicated by the Device character. Selection of the appropriate character value is influenced by the type of graft (auto, nonauto or synthetic) and whether the graft was used alone or in combination with an interbody fusion device.

CPT – In CPT, placement of graft material is not integral to the work represented by the CPT code for the spinal fusion. Graft placement is reported separately with an add-on code that indicates the type of graft material used (auto vs. allo) and for autografts, where the graft was obtained (local vs. separate incision) and the form of the graft (morselized vs. structural).

Harvesting of Bone Graft

ICD-10-PCS – Coding guideline B3.9 indicates that harvesting of an autograft (e.g., bone graft) is reportable as an independent procedure when the graft is obtained from a separate site.

CPT – Harvesting of the graft material is included in the work represented by the CPT code assigned to report the bone graft.

Spinal Instrumentation/Fixation (Rods, screws, hooks etc.)

ICD-10-PCS – Insertion of fixation devices (rods, plates, screws etc.) to accomplish fusion of the spine is not assigned an additional code(s) when working in ICD-10-PCS as these procedures are integral to the root operation Fusion. See AHA Coding Clinic, 3rd Qtr. 2014, pages 30-31 and ICD-10-PCS coding guideline B3.1b.

CPT – Insertion of spinal instrumentation is reported separately when coding spinal fusion procedures with CPT codes. Code selection is made based on the type of instrumentation (segmental, non-segmental or intervertebral), the approach used to reach the site of insertion (anterior or posterior) and the number of vertebral segments involved. If more than one type of instrumentation is used, all the codes needed to fully report the extent of the procedure should be assigned.

Insertion of Bone Morphogenetic Protein (BMP)

ICD-10-PCS – If facilities decide to collect the information, insertion of BMP is separately reportable with a code from the Administration Section of ICD-10-PCS.

CPT – Insertion of BMP is separately reported with the assignment of an add-on code when reporting spinal fusion procedures with CPT codes.

Summary of Separately Reportable Procedures

Separately Reportable Included in Procedure Code
Discectomy PCS CPT
Bone Grafts CPT PCS
Harvest Bone Graft (Separate Size) PCS CPT
Spinal Instrumental/Fixation CPT PCS
Insertion of BMP CPT and PCS N/A

 

Time associated with Established Patient Office Visits (Total time on the date of encounter)

Of course there is much more to coding spinal fusion procedures in either CPT, ICD-10-PCS or both than was covered here, but knowing what accessory procedures should or should not be reported for each code set is a good start to getting the coding right!

For more technical coding help, check out the MRA blog here.

Find more PCS Coding help here.

Find more CPT Coding help here. And check in on the biggest CPT code updates here.

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