October 1st brought over 3,500 new codes, almost 2,000 code revisions and 600 code deletions. As a result most training for the code updates focused on new and revised codes. However, there were some important deletions that will facilitate more accurate coding and reporting for spinal fusions. Most coding errors occur when assigning the device and/or qualifier characters and the 2018 table revisions restrict assigning illogical device and qualifier values together. This change involved creating a separate row for the device character “A = Interbody Fusion Device” and providing Qualifier values for only the anterior column. In an interbody spine fusion the cage, bone dowel, Optimesh or other device with or without bone graft, is placed in between two vertebral bodies, where the disc usually lies, which by definition is the anterior column. Interbody fusion devices are never used for spinal fusions of the posterior column.
The Qualifier character tends to be confusing because it is classifying two important features of the surgery with one character:
- Approach – is the technique to expose the vertebral column for the fusion can either be from the front (anterior) or back (posterior) of the body. This information is normally obtained from the first paragraph of the operative report by how the patient is positioned on the table. A supine position involves placing the patient on their back with the face up so the incision is made on the front (or side) of the body indicating an anterior approach. If the patient is placed in the prone position the patient is positioned chest down on the table for a posterior approach to the vertebral column.
- Vertebral Column – Each individual vertebral bone is comprised of an anterir and posterior section. The vertebral body which is the anterior column as it is located towards the front of the body. The anterior column can fused using an anterior or posterior approach. Every structure posterior to the vertebral body (pedicle, 2 transverse and 1 spinous process, lamina and fact joints) and is considered the posterior column. The posterior column is always fused using a posterior approach.
Finally, a few tips to keep in mind for reporting additional procedure codes with spinal fusions:
- Separate codes are required for “Excision” or “Resection” of intervertebral disc(s) for each vertebral level (cervical, thoracic, lumbar) not individual discs.
- A distinct code is needed for removal of previously placed interbody fusion devices that are removed due to pseudoarthrosis and/or complication.
- Decompression of spinal nerves and/or spinal cord using the root operation “Release” is reported separately.
- An additional code is required for harvesting of bone or bone marrow if harvested from a different site requiring a new incision or approach.
- Separately report fixation devices placed above or below the level of the spinal fusion.
- A 360 degree fusion involving both the anterior and posterior column at the same level(s) requires two codes, one for the anterior column fusion and one for the posterior column fusion.