Cracking the Code
What NOT to Code for a Spinal Fusion
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When coding spinal fusion procedures, it is important to determine which procedures are integral and which are not integral. If the procedure is considered to be integral, then additional, separate codes are NOT assigned. If the procedure is not considered to be integral, then it is appropriate to assign separate codes.
*Pedicle screw instrumentation is included in the spinal fusion.
Q: A patient presents to the ED with severe lower back pain that continues to progress in severity. The physician orders a CT scan of the lumbar region. Final impression: degenerative disc disease L2-L5, herniated disc L4-L5, and scoliosis. The patient is admitted to inpatient status, and the physician performs a L2-L5 posterior lumbar interbody fusion using autologous bone graft, L2-L5 discectomy, L2-L5 pedicle screw instrumentation, and harvesting bone graft from right iliac crest through separate incision.
A: 0SG107J, fusion of 2 or more lumbar vertebral joints with autologous tissue substitute, posterior approach, anterior column, open approach 0SB20ZZ, excision of lumbar vertebral disc, open approach 0QB20ZZ, excision of right pelvic bone, open approach
Reference: Coding Clinic 3rd Q 2014: Lumbar interbody fusion of two vertebral levels-correction