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.

Reference: References: AHA Coding Clinic Third Quarter 2019, pages 35-36: Fusion Procedures of the spine
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