Full Answer
Spinal stenosis, thoracic region. M48.04 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
Spinal procedure coding can be daunting for coders. The spine itself can be quite complicated anatomically and the procedures done to address spinal conditions can be even more complicated! HIA has developed an educational Action Plan to address one of these areas, spinal decompression coding. Below are a few excerpts from that Action Plan.
Decompression is the release of pressure on a spinal nerve root or on the spinal cord itself. Decompression is necessary when patients develop radiculopathy and/or myelopathy due to spinal disease.
The Thoracic Nerve body part is identified by the character 8 in the 4 th position of the ICD-10-PCS procedure code. It is contained within the Destruction root operation of the Peripheral Nervous System body system under the Medical and Surgical section. The 4 the position refers to the body part or body region when applicable.
Lumbar decompression surgery is used to treat: spinal stenosis – narrowing of a section of the spinal column, which puts pressure on the nerves inside. a slipped disc and sciatica – where a damaged spinal disc presses down on an underlying nerve. spinal injuries – such as a fracture or the swelling of tissue.
Cervical laminectomy Laminectomy is surgery that creates space by removing the lamina — the back part of a vertebra that covers your spinal canal. Also known as decompression surgery, laminectomy enlarges your spinal canal to relieve pressure on the spinal cord or nerves.
CPT 0275T is a Category III Code assigned for this procedure. 0275T - Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy, and/or foraminotomy), any method, under indirect image guidance (eg.
ICD-10 Code for Spinal stenosis, lumbar region- M48. 06- Codify by AAPC.
decompression: opening or removal of bone to relieve pressure and pinching of the spinal nerves. discectomy: a type of surgery in which herniated disc material is removed so that it no longer irritates and compresses the nerve root.
A laminectomy the removal of the lamina, a part of the spine that forms a bony “roof” over the spinal canal. This common procedure gives a neurosurgeon access to the spinal canal and relieves pressure on the spinal cord or nerve roots.
Spinal decompression helps provide relief for patients with the following conditions: Sciatica. Spinal stenosis. Herniated or bulging discs.
Vertebral axis decompression is NOT covered in accordance with the Centers for Medicare and Medicaid Services (CMS) NCD.
S9090 is a valid 2022 HCPCS code for Vertebral axial decompression, per session or just “Vertebral axial decompressio” for short, used in Other medical items or services.
04.
061 Spinal stenosis, lumbar region without neurogenic claudication.
Spinal stenosis and foraminal stenosis describe the narrowing of the canals in your spine. Spinal stenosis is the narrowing of the canals through which the spinal cord travels, foraminal stenosis is the narrowing through which the spinal nerves travel before exiting the spine.
The implementation of ICD-10-PCS has enhanced the skills of coding professionals as it contains many unique features that provide an opportunity to accurately reflect the complexity of the procedures being performed. The assignment of ICD-9-CM procedure codes for spinal fusions often challenged coding professionals, and this has not changed with the transition to ICD-10-PCS. As with the coding of other complex surgical procedures, coding professionals struggle with identifying which portion of the spinal fusion procedure to code or not to code.
The codes for the anterior spinal fusion are 0SG00AJ (L4-L5) and 0SG30AJ (L5-S1) . Two codes are also assigned for the posterior spinal fusion, 0SG0071 (L4-L5) and 0SG3071 (L5-S1) . Codes 0SB20ZZ and 0SB40ZZ are also assigned for the discectomy performed at two different levels of the spine. Lastly, code 0QB20ZZ is assigned for the harvesting of the right iliac crest bone graft.
The code for this procedure is 0QB20ZZ, with the body part character (fourth character) being 2 for right pelvic bone. The iliac crest does not have its own distinct body part value in ICD-10-PCS, with the ICD-10-PCS Body Part Key indicating that the pelvic bone is the closest proximal branch.
Qualifier: The qualifier character identifies the column of the spine being fused (anterior or posterior) and if the surgical approach is from the front or back of the body (see Figure 1 below).
As with Examples #1 and #2, the segmental instrumentation is included in the spinal fusion and is not coded separately. The lumbar decompression L4-L5 and L5-S1 bilateral foraminotomies and L3 decompression laminectomy are also considered to be integral to the spinal fusion and not coded separately.
Spinal stenosis, lumbar region 1 Lumbar spinal stenosis no neurogenic claudication 2 Lumbar spinal stenosis w neurogenic claudication 3 Myelopathy due to spinal stenosis of lumbar region 4 Neurogenic claudication co-occurrent and due to spinal stenosis of lumbar region 5 Neurogenic claudication due to spinal stenosis of lumbar region 6 Spinal stenosis lumbar region 7 Spinal stenosis lumbar region, neurogenic claudicati 8 Spinal stenosis of lumbar region 9 Spinal stenosis of lumbar region with myelopathy 10 Spinal stenosis of lumbar region without neurogenic claudication 11 Spinal stenosis of lumbar spine 12 Stenosis of lumbar spine with myelopathy
The 2022 edition of ICD-10-CM M48.06 became effective on October 1, 2021.
Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure
When coding, if the patient has a diagnosis of spinal stenosis, claudication, radiculopathy or myelopathy and is undergoing spinal surgery, chances are that a release of the spinal nerve, spinal cord or both will be completed.
Decompression is necessary when patients develop radiculopathy and/or myelopathy due to spinal disease. By releasing the herniated disc or other spinal condition that is irritating or pinching the nerve, the nerves are freed and should relieve the pain (radiculopathy/myelopathy) associated with this.
If both, spinal nerves and spinal cord are released, both should be coded.
The code assignment depends on the site of the release and what is being released. Remember, the definition of release when coding in ICD-10-PCS is “freeing a body part from an abnormal physical constraint by cutting or by use of force.” The body part value for the ICD-10-PCS code would be the body part being freed and NOT to the tissue being moved/excised to free the body part.
Decompression is the general term to describe removal of the spinal disk, bone, or tissue causing pressure and pain. Often, this is the only procedure performed. Examples include: laminectomy to decompress spinal canal and/or nerve roots (e.g., 63001-63017, 63045-+63048), discectomy to decompress spinal canal and/or nerve roots (e.g., 63020-+63035, 63040-+63044, 63055-+63057), corpectomy (e.g., 63081-+63091), fracture repair (e.g., 22325-+22328), etc.#N#CPT® designates the decompression codes as being per “vertebral segment” or per “interspace.” Decompression occurs at the interspace for discectomy codes (e.g., right L4-L5 interspace). Discectomy is a single, standalone code, such as 63030 Laminotomy (hemilaminectomy), with decompression of nerve root (s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar.#N#But decompression of the spinal canal can be coded per vertebral segment (63001-63017), or per level of foraminotomy (e.g., decompression of the L4 exiting nerve root via partial laminectomy at L4 and partial laminectomy at L5, with foraminotomy at L4-L5, is reported using one code: 63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root [s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar).#N#Discern whether the approach was posterior or anterior to choose the correct code. Table A illustrates commonly used, standalone decompression codes for spine surgery.#N#Table A: Standalone decompression codes for spine surgery
“It seems like coding spine cases is as complicated as doing the surgery,” said a spine surgeon at his first coding training session with me.#N#Spine procedure coding can make even the most confident coder squirm. But spine procedure coding doesn’t have to be difficult. In fact, it’s quite formulaic. Follow these five principles and spine procedure coding will go from scary to simple.
Because a fusion was performed, you must include a bone graft code. As with other graft codes in CPT®, the spinal bone graft codes are reported for harvesting the bone graft. The work of placing the bone graft is included in the arthrodesis/fusion codes. All spinal bone graft codes are add-on codes.
Warning: As with bone graft codes, instrumentation codes are add-on codes, and are never reported with modifier 62. Some payers (including Medicare) will incorrectly reimburse the instrumentation and some bone graft codes when billed with modifier 62; however, CPT® guidelines prohibit reporting the instrumentation and bone graft codes with modifier 62.