Coding Spinal Procedures
By Selena Chavis
For The Record
Vol. 34 No. 4 P. 10
These cases can create a lot of angst for coders, but industry experts say it’s possible to overcome any trepidation.
The spine is a complex, important part of the body. The smallest ailment can have a dramatic, far-reaching impact. In a similar fashion, experts say the intricacies of the spine can also present multifaceted challenges for coders.
“A large part of the complexity is due to the anatomy of the spine,” says Deanna Upston, CCS, CPMA, COSC, CPC, senior coding quality auditor with the Haugen Consulting Group. “There are many guidelines in the [American Medical Association] CPT book and the CMS National Correct Coding Initiative that coders need to know.”
Upston points out that coders need to understand everything from the bony anatomy, which includes three spinal regions plus the sacrum, to the 24 vertebral levels and what makes up each part of the bony vertebrae. Outside of the bony anatomy, there are also neurological components, such as where the nerve roots exit each vertebra, that must be considered. Notably, each vertebral level can have distinct procedures performed, so a coder may need to assign several CPT codes to most cases.
Just understanding which structure a procedure is performed on is complicated, says Lori Amende, RHIA, CCS, a product specialist with TruCode. “As an example, let’s consider a decompressive laminectomy of the spinal cord and spinal nerve,” she says. “These structures have similar names and are very close in location but are reported with different ICD-10-PCS procedure codes.”
Renee Friesen, CCS, CCS-P, CAH-CBS, coding auditor/trainer with TruBridge, points out that spinal procedures can be performed on the anterior column (vertebral body) or posterior column (lamina, spinous processes, foramen, or facets) using an anterior (front), posterior (back) or lateral approach.
All these factors have significant influence on coding. “Documentation should be reviewed carefully since the approach and column can determine code assignment for some procedures,” Friesen says. “Additionally, there can be confusion around counting the number of spinal levels. In January 2022, CPT revised the arthrodesis section, replacing ‘level’ with ‘interspace’ to clarify that each interspace should be counted.”
Devices and materials used in spinal procedures also impact coding, Friesen adds. For example, in ICD-10-PCS, some of these devices are integral to the procedure and some are not. Rods, plates, and screws used during a spinal fusion are not considered when choosing a procedure code. However, interbody fusion devices and bone grafts are important components of the spinal fusion codes.
Wendy Gorrie, RHIT, CCS, CPC, CIC, an outcome solutions architect with Axea Solutions, emphasizes that coders also need to understand that the codes they assign are important to ensure quality data collection that can, for example, pinpoint how many procedures are performed in certain geographical areas. “Most medical coding professionals are driven to assign correct codes and take great pride in navigating tricky coding circumstances,” she says. “However, many coding professionals do not find the assignment of (ICD-10-PCS) spinal procedure codes as easy as 1, 2, 3. This is likely due to the fact that each spinal procedure requires multiple codes, which will contain no less than seven alphanumeric characters and dozens of ‘if this, then that’ thought processes behind each character choice.”
Where Are Knowledge Gaps Occurring?
When coding spinal procedures, it can be difficult to determine the objective of the procedure, according to Amende. From the start, the coder must be able to interpret the documentation and then apply that to the ICD-10-PCS coding system. Offering an example, Amende points to a physician who documents “anterior vertebral tethering.” In this case, the coder would need to understand that the objective of the procedure is repositioning performed to correct spinal scoliosis.
Understanding the difference between segmental and nonsegmental can be challenging when assigning CPT codes, Friesen notes. “Segmental is three or more points of attachment. I tend to train coders to look for the number of screws placed,” she says. “For example, if six or more screws are placed, you are probably dealing with segmental. Nonsegmental is posterior fixation at the top proximal hook and the bottom distal hook. The fixation is on each end of the construct and nowhere in between. Pretty easy thought process, right?”
Difficulties also can arise when assigning diagnosis codes for spinal disorders, says Amende, who points to the “with” guideline as being particularly problematic. According to the Official Guidelines for Coding and Reporting, the words “with” or “in” should be interpreted to mean “associated with” or “due to” when they appear in a code title, the Alphabetic Index (either under a main term or a subterm), or an instructional note in the Tabular List.
“What’s often overlooked regarding the ‘presumed linkage’ between two terms using the word ‘with’ is that the presumed linkage is dependent on the condition having an entry within a code title, Alphabetical Index, or Tabular List, not provider documentation,” Amend says. “It’s only when ‘with’ is listed within these three areas that the term means ‘associated with’ or ‘due to.’”
Gorrie suggests that gaps in knowledge tend to pool behind several different characters of ICD-10-PCS codes and trend into the following four categories:
• root operations;
• body parts;
• devices; and
• qualifiers identifying approach.
“The first match a coder makes between surgical documentation and the coding manual involves anatomical body parts,” Gorrie says, pointing to the fact that the spinal column refers to 33 vertebral bones divided into multiple levels, such as cervical, thoracic, and lumbar. “These levels are further broken down into multiple joints at each level.”
The second decision coders make is which root operation most closely fits the surgeon’s intent. Gorrie notes that spinal surgery is not always fusion. “Official coding instruction states that spinal fusion must include some type of bone graft. Sometimes, spinal surgery may be performed to stabilize bones with rod and screw instrumentation without fusion,” she says.
Third, Gorrie says that if a bone graft is used, coders must determine where the graft came from, such as the patient’s own body, an animal, or a synthetic source. And finally, coders must interpret anatomical directional terms to understand not only how the surgeon accessed these structures beneath the skin but also whether procedures were performed on the back or front parts of the spinal column.
Upston asserts that “clear operative documentation is crucial to correct coding.” Details should include, at minimum, the following:
• patient position;
• approach, including incision and then approach to the vertebra;
• guidance, if used;
• diagnostic indications, such as stenosis or herniated disc, or fracture, and which levels are affected;
• exact procedure performed at each level;
• exact placement location of the instrumentation and type of instrumentation;
• if decompression is performed, identifying the nerve roots decompressed; and
• specifying the number of vertebrae removed during a corpectomy.
To facilitate correct code assignment, surgical note documentation must either be comprehensive from the moment of dictation or addended on the back end to provide any missing information, Gorrie says. “Documentation must describe components in root operation definitions and body parts to begin the coding pathway. The surgeon’s words provide landmarks as the coder moves down the path, describing the patient’s position on the surgical bed, whether a large open incision was made, or if the procedure was accomplished minimally invasively using an endoscope,” she says. “Other terms are road signs for the coder indicating intervertebral cages filled with bone graft, or the removal of body parts and how many joints of the particular vertebral level were involved in the procedure.”
Coders should have a clear understanding of conditions that could require additional treatment, Amende says. For example, she points to placement of an interspinous distraction device (spacer) to treat spinal stenosis performed in conjunction with a spinal fusion procedure. Insertion of the spacer has a separate and distinct objective and can be reported separately.
In regard to CPT, Friesen notes that it’s important to make sure documentation supports medical necessity criteria for the procedure performed. “This criterion does change periodically,” she says, pointing to recent updates to spinal injection procedures in which “radiculopathy” was added as a covered diagnosis in December 2021. “Because of these changes, it’s crucial to have all relevant diagnoses included in the record.”
Spinal Fusion Devices and Reimbursement
Reimbursement for inpatient encounters is heavily impacted when a spinal fusion procedure occurs, Gorrie points out, making this area critical for optimizing revenue. “The reimbursement amount may rise or drop dramatically if even one character out of seven incorrectly matches existing documentation,” she says. “For example, thousands of dollars represent the difference in work, expertise, and resources between fusion of a single joint at one spinal level compared to fusion of multiple joints at multiple spinal levels involving approaches from both anterior and posterior sides of the patient’s body.”
Friesen emphasizes the importance of including all appropriate add-on codes when coding spinal procedures in CPT. “A great example is codes for bone grafts—morselized allograft or autograft—used during a procedure. They often do not have a work relative value unit associated but it’s very important to report them correctly,” she says.
Currently, there are several devices used in spinal procedures that are identified as new technologies, Amende notes. These include the SpineJack system, magnetically controlled growth rods, dynamic distraction devices, and certain interbody fusion devices. “When these devices are used, they qualify for additional reimbursement,” Friesen says. “The new technology ICD-10-PCS codes can be updated in April and October of each year, so coders must stay abreast of these changes to ensure correct code assignment and reimbursement.”
Collaboration is key to process improvement and ensuring revenue is not lost, says Upston, who adds that communication should be ongoing between surgeons, coders, and preauthorization and revenue cycle professionals. “Coders should work with surgeons to make sure they document all the procedures they are performing in a precise manner so that correct CPT codes can be assigned,” she says. “Revenue cycle needs to be in communication with the coders and the surgeons on denial reasons, and the preauthorization department needs as much information as possible to make sure they are requesting authorization for the correct procedures.”
Gorrie points to the importance of consistent education and training, suggesting that coders are known for consistently requesting comprehensive education, which includes opportunities for pertinent practice. “However, specific spinal procedure coder education is not always amply available,” she notes. “High-quality education results in a clean code list, triggering correct reimbursement with the submission of the first claim. In addition, clinical documentation improvement staff require similar education to pass on to physicians as necessary, which will ensure adequate documentation at first dictation to cut down revisit time spent answering queries.”
In summary, Gorrie says the aptitude and skill involved in the complexity of spinal procedure coding are like comparing trigonometry with basic math. “Wise coding managers recognize the high value of coding professionals possessing current education while they dissect spinal fusion operative reports,” she says. “Capturing critical medical statistics rests on the shoulders of the coding professionals found daily bent over their computer keyboards. Medical coders understand the purpose of code capture is not just about reimbursement for services provided to patients; they also understand that their codes are tossed like data seeds into a vast data collection system.”
While challenging, Upston says that coders should not feel intimidated by spinal procedures coding. “I think some coders might wonder why anyone would want to work in spine coding, and to that I would say it’s because it is so rewarding,” she says. “It is one of the most challenging but fascinating areas to learn and never boring.”
— Selena Chavis is a Florida-based health care writer.