 by Selena Chavis The spine is a complex, important part of the body. The slightest ailment can have a dramatic, far-reaching impact. This, along with many other factors, significantly influence coding. In the Fall issue of For the Record, a comprehensive article on Coding for Spinal Procedures by Selena Chavis examines various coding challenges and shares tips from coder expert contributions, including some from Wendy Gorrie, an outcome solutions architect with Axea Solutions. Wendy Gorrie, RHIT, CCS, CPC, CIC, an outcome solutions architect with Axea Solutions, emphasizes that coders also need to understand that the codes they assign are important to ensure quality data collection that can, for example, pin point how many procedures are performed in certain geographical areas. “Most medical coding professionals are driven to assign correct codes and take great pride in navigating tricky coding circumstances,” she says. “However, many coding professionals do not find the assignment of (ICD-10-PCS) spinal procedure codes as easy as 1, 2, 3. This is likely due to the fact that each spinal procedure requires multiple codes, which will contain no less than seven alphanumeric characters and dozens of ‘if this, then that’ thought processes behind each character choice.” Gorrie suggests that gaps in knowledge tend to pool behind several different characters of ICD-10-PCS codes and trend into the following four categories: • root operations; • body parts; • devices; and • qualifiers identifying approach. “The first match a coder makes between surgical documentation and the coding manual involves anatomical body parts,” Gorrie says, pointing to the fact that the spinal column refers to 33 vertebral bones divided into multiple levels, such as cervical, thoracic, and lumbar. “These levels are further broken down into multiple joints at each level.” The second decision coders make is which root operation most closely fits the surgeon’s intent. Gorrie notes that spinal surgery is not always fusion. “Official coding instruction states that spinal fusion must include some type of bone graft. Sometimes, spinal surgery may be performed to stabilize bones with rod and screw instrumentation without fusion,” she says. Third, Gorrie says that if a bone graft is used, coders must determine where the graft came from, such as the patient’s own body, an animal, or a synthetic source. And finally, coders must interpret anatomical directional terms to understand not only how the surgeon accessed these structures beneath the skin but also whether procedures were performed on the back or front parts of the spinal column. “Most medical coding professionals are driven to assign correct codes and take great pride in navigating tricky coding circumstances,” she says. “However, many coding professionals do not find the assignment of (ICD-10-PCS) spinal procedure codes as easy as 1, 2, 3. This is likely due to the fact that each spinal procedure requires multiple codes, which will contain no less than seven alphanumeric characters and dozens of ‘if this, then that’ thought processes behind each character choice.” Link here to For the Record, and read the article in its entirety.
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