Introduction to Spine Coding:Introduction to …

1 1 Introduction to Spine Coding:Introduction to Spine coding :The four ElementsPresented by: Barbara Cataletto, MBA, CPCB usiness Dynamics, LLCB usiness Dynamics, LLCThe Business of SpineThe Business of Spine , 16955 Walden Road, Suite 114, Montgomery, TX 77356 Phone: 888-337-8220 The following presentationsare not to be considered a replacement for the Current Procedural Terminology(CPT) book or the International Classification of Diseases 9th Revision-Clinical Modification(ICD-9-CM) book. It is designed simply as a resource to help you obtain a better understanding of Spine coding . Always refer back to the full Current Procedural Terminology(CPT) book when (CPT) ii ht 2010 AiM di l Current Procedural Terminology(CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listing are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

2 CPT is a trademark of the American Medical Association. International Classification of Diseases 9th Revision-Clinical Modification(ICD-9-CM) is copyright 2010 Ingenix. All Rights Reserved. Education Disclaimer:The information provided is general coding information only -it is not legal advice; nor is it advice about how to code, complete or submit any particular claim for payment. It is always the provider s responsibility to determine and submit appropriate codes, charges, modifiers and bills for services rendered. This coding and reimbursement information is subject to change without notice. Before filing any claims, providers should verify current requirements and policies with the 2011 Professional EditionThis reference material is the responsibility and under the ownership of the American Medical Association. Updates and modifications are made yearly to reflect changes in medical :The diagnosis; the reason for the four elements of Spine CodingHOW:How are you getting there, what approach?

3 WHERE:Where is the anatomical location?WHAT:What is it that you are doing?3 Primary DiagnosisMain ApproachThe four elements of Spine CodingMain LocationMain ProcedureCoding descriptors do not necessarily follow the surgeon s DIAGNOSIS4 ICD-9-CM Primary DiagnosisThis reference material is the responsibility of thethe responsibility of the World Health OrganizationAnd their main responsibility is to track diseases and illnesses throughout the worldLesionPrimary DiagnosisNeoplasmDeformitySpinal Condition5 Primary DiagnosisNeoplasm - new and abnormal growth of tissue, eg: malignant tumorsLesion-Any pathological or traumatic discontinuity ofLesion -Any pathological or traumatic discontinuity of tissue or loss of function of a part, eg: infectionsDeformity -A permanent structural deviation from the normal shape or size, eg: scoliosis, kyphosis, etcSpinal Condition- Spine related condition eg:stenosisSpinal Condition Spine related condition, eg: stenosis, disc herniation, spondylosis,etcNeoplasm vs.

4 Spinal ConditionCorpectomy for Myelopathy:Cervical Spine Code 63081 ICD9 721 1 ICD-9 for Neoplasm:Cervical Spine Code 63300 ICD-9 198 5 ICD9 vs. Spinal ConditionLumbar Laminectomy for Lesion other than Herniated DiscCPT Code: 63267 Diagnosis Osteomyelitis: Laminectomy including Laminectomy, Facectomy,and ForaminotomyCPT Code: 63047 Diagnosis: Spinal Stenosis: 724 02 Diagnosis: Spinal Stenosis: Revision Surgery vs. Deformity CorrectionFlat back syndrome, recurrent spinal stenosis, painful hardware: ICD-9 , , etcCoding ranges include decompression and fusion coding at each : 63042, 63044, 22612, 22614, adult idiopathic scoliosis: ICD-9 dii li it d tifidifd fitCoding range is limited to very specific code groupings for : 22800 or 22810 or 22812, APPROACHMain ApproachAnteriorPosteriorExtracavitaryLa teral8 Main ApproachCoding designated by approach, regardless of where you end upFor example:No posterior corpectomy codesAnterior interbody fusion is not possible via posterior approachEach approach should have its own operative procedures require separate operative Anterior/Lateral2.

5 Transthoracic3. Thoracolumbar4. Retroperitoneal1. Anterior Lateral633002. Transthoracic63301 Anterior3. Thoracolumbar633024. Retroperitoneal63303101. Posterior Lateral2. TranspedicularPosterior3. CostovertebralExtracavitary Lateral1. LOCATIONC ervicalThoracicMain LocationThoracicLumbarSacral12 CervicalThoracicMain LocationThoracicLumbarSacralExample:Stat e All Levels and InterspacesT5 L3 fusion for fusion for Identify the Exact LocationUsing the basic concept ofUsing the basic concept of labeling, referencing the exact anatomical location, is critical to the coding processProperly Identify the Exact LocationVertebral Interspaces with a - : C3-C4, C4-C5 for interspaces for Segments with , : C3, C4, C5 for segments of Identify the Exact LocationVertebral interspaces with - : T3-T4, T4-T5 : T3T4, T4T5 for interspaces for segmentswith , : T3, T4, T5 for segments of 2: Patient has severe Spondylosis and Disc Herniation from C3-C6 Identify Different Locations ProperlyOperative note indicates the Procedures Performed Cervical DiscectomyCervical CorpectomyIn this case codes are consideredbundledIn this case, codes are considered clarification allow for appropriate coding of Procedures Performed Cervical Discectomy C3 C4: 63075 Identify Different Locations ProperlyCervical Discectomy C3 C4: 63075 Cervical Corpectomy C5, C6: 63081, 63082In this case, codes are considered notbundled, as they are at different levels.

6 *Carrier rules applyIdentify Different Locations ProperlyExamples:Patient has disease from L3-S1Op notes states Procedure Performed Lumbar Interbody FusionLumbar Lateral FusionLumbar LaminectomyCdildb fdifftbi tiCoding could be of many different combinations16 Further clarification indicates that the Procedures Performed Lumbar Interbody Fusion L4-L5: 22630 Identify Different Locations ProperlyyLumbar Lateral Fusion L4-S1: 22612, 22614 Lumbar Laminectomy L3,L4,L5: 63047, 63048 X 2*In addition, there were additional implants, grafts and instrumentation utilized. *Carrier rules applyMAIN PROCEDURES17 DecompressionFusionGraftingItttiMain ProceduresInstrumentationExplorationOste otomiesFracture TreatmentInjectionsMiscellaneousMain Procedures: Account for EverythingExample:DecompressionLateral Fusions Interbody FusionInstrumentationImplantsGrafts18 MAIN PROCEDURES:DECOMPRESSIONSD ecompressions Main Procedures: DecompressionsCoding is based on the interspace and levels and degree ofdecompression and are certainly diagnosis based.

7 Most difficult coding in Spine 19 There are several types of decompressionsMain Procedures: DecompressionsThere are several types of decompressionsthat may be performed during the surgical main coding difficulty lies in the language used by the surgeon to describe the type and difficult to decipher. Extent and diagnosis Examples Represent Cervical Procedures:Main Procedures: DecompressionsLaminotomy: 63020, 63040 Laminectomy: 63001, 63015, 63045, 63265, 63275 Corpectomy / Vertebrectomy: 63081, 63300, 63304 Laminoplasty: 63050, 6305120 Main Procedures: DecompressionsLaminectomy or Corpectomy for: Spinal Condition Neoplasm LesionDiagnosis and location will determine the appropriate codeMain Procedures: Types of Decompression Corpectomies: The 50/30 rule: -50% removal for cervical-30% removal for Lumbar30% removal for Lumbar No anterior discectomy code for cervical or lumbar in combination with a fusion The diagnosis and degree of decompression willof decompression will determine the code selection21 Main Procedures.

8 Fusion/Decompression ChangesCervical fusion and discectomyCPT CODES 22551 & 22552replace the use of codes 63075 with 22554 and 63076 with 22585when performed in combination with surgeons or PROCEDUREFUSION22 Differentiation of Reconstructive Procedure vs. Corrective Procedure vs. Stabilizing Procedure:Main Procedures: FusionLateralDeformityInterbodyDocument and code for explorationDocument and code for explorationClarity in the fusion procedure is absolutely necessary to code. Main Procedures: FusionThe cases that involve reconstruction and revisionmust be documented as such and should not be considered a deformityunless it is a pure scoliosis or kyphosis case for curve Procedures: FusionNumber of Levels and Location MattersLateral: 22600-22614 Deformity:2280022818 Deformity: 22800-22818 Interbody: 22554- 22585, 22630-22632 Specific areas of fusion: 22590-22595 These are just examples of the numerous fusion codes availableMain Procedures: Types of FusionAlthough the term fusionshould satisfy thedocumentation requirements, itis necessary to discuss theis necessary to discuss theother components leading up tothe fusion dictate the levels ofdecortication and thesubsequent laying of graft orsubsequent laying of graft orother materials to support thecoding24 Main Procedures.

9 Types of FusionDescribe all the types of fusionsperformed in the not make the assumption thatthe reviewer or coder will knowexactly where and what type offusion was levels of fusion PROCEDURESMAIN PROCEDURESGRAFTING25 Autograft vs. AllograftStructural vs. Non-StructuralMain Procedures: GraftingStructural vs. NonStructuralSame-site, separate incision, bone for all procedures specific graft codes are in the 20930-20938 rangeMain Procedures: Types of Grafting26 Main Procedures: Types of GraftingThe type of grafting matters as the coding changes based on the graft materials usedon the graft materials usedThere are so many different products or grafting possibilities that the coder may not even know that the opportunity to code is there without guidancewithout guidanceMain Procedures: Types of Graftingand don t forget bone marrow aspiration27 MAIN PROCEDURES INSTRUMENTATIONI nsertion, removal, reinsertionPlating, pedicle screws, rods, Procedures: InstrumentationPlating, pedicle screws, rods, segmental vs.

10 Non-segmentalIdentify all levels of placementIdentify by brand name28 Non-segmental Instrumentation: Posterior:22840 Segmental Instrumentation: Posterior:22842-22844 Main Procedures: InstrumentationSpinous Process Wiring: Posterior: 22841 Biomechanical Devices: Anterior/Posterior:22851 Anterior Instrumentation: Anterior:22845-22847 Pelvic Instrumentation: Posterior:22848 Main Procedures: Types of InstrumentationInstrumentation isbilled by construct type and notably bytype, and notably bythe number of levels orinterspaces involved,along with theanatomical placementof the Procedures: Types of InstrumentationNonsegmental vsSegmental InstrumentationPosterior Only:Noted by the specificareas where theattachments are madeattachments are Procedures: Types of InstrumentationCode 22851 Biomechanical devicecodes are billable for eachinterspace where implantsare Procedures: Types of InstrumentationBill all of the instrumentation for the are codes available for all of these is necessary to document properly, as they are not billable Main Procedures: InstrumentationRemoval / Insertion / Reinsertionin certain Includes:22849 Reinsertion of Instrumentation22855 Removal of Anterior Instrumentation22850 Removal of Posterior Non-Segmental Instrumentation22852 Removal of Posterior segmental Instrumentation31 Anterior and PosteriorMain Procedures: OsteotomyAccount for all segments by anatomical locationOften performed with fusion for deformity bill for both anterior and posterior osteotomy proceduresDt bill didt thllDo not bill decompression codes at the same levelMain Procedures: OsteotomyCode for Both TypesSmith Peterson22212- 22226 Pedicle Subtraction22206-22208Do not bill decompression dtthllcodes at the same PROCEDURESMAIN PROCEDURESFRACTURE TREATMENTMain Procedures.