Spinal Surgery PCS Coding Can Be Challenging, But Not Impossible!

surgeon showing a spinal surgery x-ray with supporting medical coding information to a patient

Medical Coders have often faced challenges with coding spinal surgeries due to their intricate nature. The complexity can escalate when coding within the ICD-10-PCS framework. However, by following accurate medical coding guidelines and references, coders can confidently assign the correct PCS codes. A solid understanding of spinal anatomy and coding guidelines is crucial for Medical Coders to excel in this area.

For a good reference regarding spinal anatomy, please check out:

  • https://orthoinfo.aaos.org/en/diseases–conditions/spine-basics/

It is also important to have a good understanding of the different types of spinal surgeries. Remember that the intent of the procedure will help guide the coding. For example, a decompression laminectomy performed to decompress the spinal cord or spinal nerve is different from a laminectomy done as the approach to a spinal fusion.

Here are some examples of spinal surgeries that are performed, and some PCS coding tips:

Laminectomies can be performed to decompress the nerve root, excise a synovial cyst or to release the spinal cord. These are coded to the Root Operation of Release. Always look at the intent of the procedure, because if the laminectomy is only done as the approach to another spinal procedure, it is not coded in ICD-10-PCS.

Discectomies are performed to removal an entire spinal disc or a portion of the disc. This is done to relieve the compression on the spinal nerve or spinal cord. In ICD-10-PCS, a total removal is coded to the Root Operation of Resection and when only a portion of the disc is removed, it would be coded to the Root Operation of Excision.

Kyphoplasties/Vertebroplasties are performed to repair vertebrae fractures. The Kyphoplasty is the portion of the procedure where a balloon is inserted to restore the vertebral height. The Vertebroplasty is the portion of the procedure where cement like material is inserted to stabilize the fracture. In ICD-10-PCS, the kyphoplasty portion is coded to a Root Operation of Reposition. The Vertebroplasty is coded to the Root Operation of Supplement. There are instances where a vertebroplasty may be performed with no kyphoplasty procedure, so it is important to carefully read the Operative reports.

Spinal fusions are performed to fuse the vertebra together to prevent movement between them. Fusions are performed with bone graft or an interbody fusion device. One of these must be present for a fusion to be done. Fixation devices such as rods, screws or plates do not require a code in PCS when coding the fusion, only the bone graft or synthetic substitute would be coded. Spinal fusions can be done with an anterior or posterior approach. It is important to know which approach is used because sometimes a fusion is performed both anteriorly and posteriorly and both would be coded in PCS.

The Official Coding Guidelines are very helpful with spinal fusion surgery information. (Guideline B3.10a, B3.10b and B3.10c) https://www.cms.gov/files/document/2023-official-icd-10-pcs-coding-guidelines.pdf

Although they can be tricky, if you know what the intent of the procedure is and the spinal anatomy, medical coders can successfully code any spinal surgery in ICD-10-PCS.

Since 1986, MRA has provided coding and auditing support services to a diverse range of healthcare facilities. With our comprehensive expertise, we offer flexible solutions, including both staff augmentation and complete outsourcing options, tailored to meet your hospital or healthcare organization’s specific needs.

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