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Fall 2006

Coding Corner: Documenting Spinal Surgery

Jody Locke
Vice President, Anesthesia Business Consultants, LLC

Speakers at anesthesia coding seminars often harp on the importance of indicating the use of hardware when documenting spinal surgery. The argument is that failure to indicate the use of hardware will result in the loss of five billable units. While it is useful to keep this in mind when reporting spinal procedures, this is hardly the end of the story. New surgical techniques make it imperative that not only is the surgical approach and location clearly indicated, but that the coders understand the significance of each indication.

A case in point is a practice that routinely reported a spinal procedure indicated as “TLIF.” The indication obviously made sense to the anesthesiologists, but was not at all clear to the coders. A review of various reference materials indicated the following options for which the corresponding anesthesia basic values are indicated. Another physician reported a procedure as “ACDF,” which was interpreted as Anterior Diskectomy with fusion and the coder selected CPT code 22554. A review of a standard coder’s reference indicated such a procedure does not typically involve instrumentation. A review of the surgical operative report, however, clearly indicated the use of plates and screws. This clarification resulted in a base value of 13 instead of 10.

The bottom line is that the placement or removal of plates, screws, rods, cages or dowels during spine surgery should be clearly noted together with the level of the procedure. It is always a good habit when providing anesthesia for a procedure that is new to your practice to confirm the best way to document the surgery so that the coders will be able to code it appropriately. For ABC clients this is a standard part of the service.

Thoracic Lumbar 8 units

Interbody Fusion

Transforaminal Lumbar 8 units

Interbody Fusion

Translaminar Instrumentation 13 unit with Fusion