Here are six things to know:
1. To correctly assign a code for a spinal fusion, knowledge of spinal anatomy and physiology will be helpful. First, denote the proper qualifier:
• Anterior approach, anterior column
• Posterior approach, posterior column
• Posterior approach, anterior column
2. Identifying the approach can be difficult, because the approach doesn't necessarily correlate with the column on which the surgeon performed. It's important to note that no code exists for the anterior approach alone, but rather there will be two reports involved.
3. After a coder has identified the approach, the next step involves pinpointing the part of the spine undergoing fusion. Determining this may also prove challenging as spinal fusions often include various devices. For example, the use of an interbody fusion device will indicate fusing of the anterior column. Refer to ICD-10-PCS Guideline B3.10c for help in identifying the device value for fusion procedures if multiple devices are used.
4. A 360-degree fusion will often trip up coders, because it involves both the anterior and posterior. As a coder, ensure you closely read the operative report's body and header, taking in every word. A common mistake here involves coding only for the anterior fusion and leaving out the posterior fusion.
5. Poor coding will negatively impact data accuracy and reimbursement. Therefore, extra training in spinal fusion coding will go a long way. Make sure the coders understand spinal anatomy and keep them up to date with new devices.
6. It may also prove helpful to designate a specialty coder who understands the ins-and-outs of spinal fusions.
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