Cracking the Code

Correctly Coding All Components of Spinal Procedures

When coding spinal procedures in the inpatient setting, it is important that coders be sure to read the operative report in its entirety. There are missed coding opportunities that are buried in the body of the operative note, which makes it even more challenging for medical coders as they are reading medical cases. Be sure to code for all levels, approaches, discectomy, and harvesting of the autograft if it’s removed from a different site than the spinal fusion.

Q: A patient underwent surgery for a transforaminal lumbar interbody fusion. The transverse processes of L5 and the sacral were dissected. Retractors and pedicle screws were placed first and used the gearshift Lenke probe to cannulate each pedicle at L5-S1 bilaterally. Transforaminal approach was performed on the right side. Facet was removed completely off the L5-S1 and harvested the bone for local autograft. A foraminotomy was performed from the outside approach and decompression of any bone was completed at the L5 nerve root. At that point, a complete discectomy was performed from the right side.
A: 0SG30AJ, fusion of lumbosacral joint with interbody fusion device, posterior approach, anterior column, open; 0SG3071, fusion of lumbosacral joint with autologous tissue substitute, posterior approach, posterior column, open; 0ST20ZZ, resection of lumbar vertebral disc, open approach; 01NB0ZZ, release lumbar nerve, open approach
Reference: AHA Coding Clinic Third Quarter 2019, pages 35-36: Fusion Procedures of the spine
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