Fusion 101 Cheat Sheet
Spinal fusion can be challenging for HIM and CDI alike. This Fusion 101 is meant to be a brief guide to coding and understanding spinal fusion.
When coding fusion, the coder needs to know the following:
- The body part value for the joint being fused.
- The position of the patient to determine the approach (anterior or posterior). This does not always indicate the column (anterior or posterior) being worked on.
- Bone graft and/or bone substitute is used, including autologous or non-autologous.
- A variety of devices can be used as noted in PCS B3.10c official coding guideline.
- Understanding procedures that are integral to the spinal fusion.
- Anterior column – The body (corpus) of adjacent vertebrae (interbody fusion).
- Anterior column fusion can be performed using an anterior, lateral or posterior technique.
- Posterior column – Posterior structures of adjacent vertebrae (pedicle, lamina, facet, transverse process, or gutter fusion).
- Posterior column fusion can be performed using a posterior, posterolateral, or lateral transverse technique.
|Body System Character – ( R) upper Joints|
|0 Occipital-cervical Joint||7 Thoracic Vertebral Joints, 2 to 7|
|1 Cervical Vertebral Joint||8 Thoracic Vertebral Joints 8 or more|
|2 Cervical Vertebral Joints, 2 or more||A Thoracolumbar Vertebral Joint|
|4 Cervicothoracic Vertebral Joint|
|6 Thoracic Vertebral Joint|
|Body System Character – (S) lower joints|
|0 Lumbar Vertebral Joint||3 Lumbosacral Joint|
|1 Lumbar Vertebral Joints, 2 or more|
Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:
- If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device.
- If a bone graft is the only device used to render the joint immobile, the procedure is coded with the device value Nonautologous Tissue Substitute or Autologous Tissue Substitute.
- If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value Autologous Tissue Substitute.
Examples: Fusion of a vertebral joint using a cage style interbody fusion device containing morsellized bone graft is coded to the Interbody Fusion Device. Fusion of a vertebral joint using a bone dowel interbody fusion device made of cadaver bone and packed with a mixture of local morsellized bone and the demineralized bone matrix is coded to the device Interbody Fusion Device.
Fusion of a vertebral joint using both autologous bone graft and bone bank bone graft is coded to the device Autologous Tissue Substitute.
See Coding clinic® 4th Quarter 2010 pages 125-129 “Spinal fusion and refusion”
For the anterior column, the body (corpus) of adjacent vertebrae are fused (interbody fusion). The anterior column can be fused using an anterior, lateral, or posterior technique.
For the posterior column, posterior structures of adjacent vertebrae are fused (pedicle, lamina, facet, transverse process, or “gutter” fusion). A posterior column fusion can be performed using a posterior, posterolateral, or lateral transverse technique.
See Coding clinic® 2nd Quarter 2009 pages 3 to 4 “Spinal Fusion procedures”
The extreme lateral interbody fusion (XLIF®) is an innovative less invasive spinal surgery of the anterior column. The XLIF® is one of several options for spinal surgery and treats specific problems, such as lumbar degenerative disc disease, spondylolisthesis, and scoliosis as well as recurrent lumbar disc displacement and lumbar spinal stenosis. However, the procedure may not be appropriate for some conditions at the lowest lumbar levels (e.g., L4-L5 or L5-S1). The fusion may be accomplished either percutaneously or via a circular tube retractor through a lateral approach. Small incisions are made in the lateral flank region with little disruption of the surrounding tissue. The disc is removed and a polyethylene (PEEK) spacer is inserted into the disc space. The position and placement of the spacer is monitored fluoroscopically along with neurophysiologic monitoring.
The direct lateral lumbar interbody fusion (DLIF) is a minimally invasive alternative to conventional spinal fusion. The DLIF is performed through a lateral approach, which allows for limited soft tissue disruption. An allograft is implanted laterally through the right or left side of the disc space. The procedure can only be performed at L4-L5 or at higher levels and requires dissection through the psoas muscle. Following discectomy, the allograft is placed and instrumentation consisting of either titanium plates or posterior pedicle screws is then inserted.
The axial lumbar interbody fusion (AxiaLIF®) is a percutaneous fusion of the anterior column at L5-S1. The AxiaLIF® system includes titanium implantable devices and instrumentation made of biocompatible materials. In the AxiaLIF®, the lumbar spine is accessed through a percutaneous incision next to the sacral bone. This approach alleviates the need for the surgeon to incise muscles and ligaments. The disc is removed and the fusion is accomplished by inserting bone growth material. This material stimulates bone growth over time in order to fuse and stabilize the spine. An AxiaLIF® 360º refers to the combination of an AxiaLIF® procedure of the anterior 4 Coding Clinic Second Quarter 2009 column performed along with a posterior column fusion which may include the use of pedicle screws or facet screws. The AxiaLIF® 360º is described as providing a percutaneous 360º fusion.
An “interbody fusion’ is a fusion of the anterior column of the spine. In traditional spinal fusion surgery, the anterior column may be fused using an anterior, lateral, posterior, or a combined (anterolateral) (posterolateral) technique. A posterior column fusion can be performed using a posterior or lateral transverse technique. The technique utilized and the column being fused may affect correct code assignment. The DLIF and XLIF® are accomplished via a lateral approach, which is more towards the back (posterior) than the front (anterior). The AxiaLIF® is performed percutaneously close to the sacrum. Therefore use code XXXX, Lumbar and lumbosacral fusion, posterior technique, for these newer techniques.
Disclaimer: AMN Healthcare encourages HIM and CDI professionals to review all resource materials associated with their area of expertise. This article does not supersede any official information published by ACDIS, AHIMA, AHA, AMA or CMS.