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Code This!

Scenario Week of January 06, 2014:
View Current Scenario

Assign the correct codes for the following scenario using ICD-9-CM diagnosis and procedure codes, ICD-10-CM and ICD-10-PCS codes and CPT procedure codes.

Indications: The patient is a 45-year old male, non-smoker, with a 4-month history of low back pain with unremitting right leg symptoms, including weakness, numbness and tingling, and was found on MRI to have L4-L5 disc herniation on the right side with myelopathy. Patient was treated conservatively with analgesics, physical therapy, and epidural steroid injection, without improvement and elected to proceed to surgical intervention.

Informed Consent: The risks, benefits, and reasonable alternatives of the procedure were explained to the patient, who elected to proceed with the procedure.

Preoperative Diagnosis: L4-L5 disc herniation on the right side with myelopathy.

Postoperative Diagnosis: L4-L5 disc herniation on the right side with myelopathy.

Operative Procedure Performed: Posterior minimally invasive microendoscopic discectomy (MED) of lumbar disc herniation utilizing METRx® Retraction MicroDiscectomy System.

Operative description: The patient was brought to the operating room and was positioned on the fluoroscopy operating table in a prone position and then prepped and draped in sterile fashion. Intravenous injection of 1g ceftriaxone was given prophylactically after general anesthesia was performed.

After filling the epidural space with contrast medium, fluoroscopic confirmation of the surgical level at L4-L5 was performed, marked on the skin by a skin marker and a small stab skin incision was made 15mm lateral to the midline on the right side and fasciotomy of the lumbar fascia was performed.

To avoid inadvertent dural penetration, in lieu of a guide wire, the smallest dilator (5.3mm) was inserted initially, with sequentially increasing dilators inserted. After inserting the final dilator, we removed the dilators, and put a finger into the opening to confirm the anatomic orientation of the posterior aspects of the surgical field. The dilators were reinserted and the 16mm tubular retractor was docked on the inter-laminar space.

The working channel of the endoscope was placed over the retractor and the angled endoscope was attached. High-quality image and endoscopic orientation were achieved by adjusting the rings of the endoscope, oriented to place the medial anatomy on the top of the video monitor (at the 12 o'clock position) and lateral anatomy on the bottom (at the 6 o'clock position), ensuring the V-shaped indicator was in the same position on the video screen as the endoscope within the tubular retractor.

A rongeur, tissue sculptor and trocar were used to resect thickened ligamentum flavum and small pieces of lamina while protecting the thecal sac, ensuring adequate exposure, proceeding from medial to lateral until the nerve root was identified. The nerve root was retracted medially using a suction retractor to expose the herniated disc.

The herniated disc fragment was removed by pituitary rongeur, with care taken to avoid putting the rongeur too deeply into the intradiscal space. After removal of the herniated fragment decompressing the nerve root, the intervertebral disc space was thoroughly irrigated with saline to remove any free fragments. Bleeding was controlled with bipolar cautery. Sodium hyaluronate was placed on the exposed dura, epidural fat, and nerve root to prevent scar formation. The instruments and tube were withdrawn and the fascia was closed with two interrupted, absorbable sutures. The subcutaneous tissue was closed with an inverted suture.

Blood loss was minimal at 65 ml. The patient was transferred to recovery in satisfactory condition, and will be observed overnight.


CODING ANSWERS

ICD-9-CM Diagnosis

722.73, Intervertebral lumbar disc disorder with myelopathy, lumbar region

Rationale:

The patient has a herniated intervertebral disc at the L4-L5 level with myelopathy. The ICD-9-CM index refers herniation, hernia to Displacement, intervertebral disc. Following the Index to Displacement, intervertebral disc, lumbar, with myelopathy, results in code 722.73. Review of the Tabular for this code confirms this is the appropriate code assignment.

ICD-9-CM Procedure

80.51 Excision of intervertebral disc

Rationale:

Procedure code 80.51, Excision of intervertebral disc is assigned for the discectomy. The laminectomy is not reported separately as it is included in code 80.51 if performed at the same level. This is confirmed by the reviewing code 80.51 in the Tabular List, with inclusion notes that state: “That by laminotomy or Hemilaminectomy.”

ICD-10-CM Diagnosis

M51.06 Intervertebral disc disorders with myelopathy, lumbar region

Rationale:

ICD-10-CM index entry “Hernia, intervertebral disc” refers to “see Displacement, intervertebral disc.” Displacement, intervertebral disc, lumbar region, with myelopathy, leads to code M51.06. Review of the Tabular List for Code M51.06 confirms code assignment.

ICD-10-PCS Procedure

0SB24ZZ Excision of Lumbar Vertebral Disc, Percutaneous Endoscopic Approach

Rationale:

The spinal discectomy documentation indicates only the herniated fragments were removed, therefore the discectomy was partial. A partial spinal discectomy is coded as an excision. See the ICD-10-PCS Index example below:

Discectomy, diskectomy
See Excision, Lower Joints 0SB

Using the PCS Table leads to the correct code assignment:
Section -0 - Medical and Surgical
Body System – S - Lower Joints
Operation – B - Excision: Cutting out or off, without replacement, a portion of a body part
Body Part – 2 – Lumbar vertebral disc
Approach - 4 Percutaneous Endoscopic
Device – Z - No Device
Qualifier – Z – No Qualifier

Approach value “4” is assigned, as this is considered a percutaneous endoscopic procedure, which is defined by ICD-10-PCS as: “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.” The entry location for this procedure was the skin, with endoscopic visualization used to reach the operative site. The laminectomy is not coded separately, as per ICD-10-PCS guideline B3.1b, which states that procedural steps necessary to reach the operative site are not coded separately. Qualifier “Z” is reported in the seventh character position, as this procedure was therapeutic rather than diagnostic.

CPT Procedure

0275T –Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

Rationale:

In this case, the visualization of the operative site was via endoscope through the retractor tube. If the visualization is performed indirectly via endoscope and/or image guidance, the procedure is considered to be percutaneous endoscopic rather than open with endoscopic assisted. Category III code 0275T is used to report percutaneous discectomy/laminectomy procedures with indirect visualization performed in the lumbar region. Code 63030 would not be appropriate, as this code is used to report open lumbar discectomy/laminotomy that is performed with direct visualization through the retractor tube, either with the naked eye, an operating microscope or loupe magnification. Endoscopically assisted discectomy/laminectomy procedures require open and direct visualization. Reference CPT Assistant July 2012 and AHA Coding Clinic for HCPCS 2nd Quarter 2011, for further guidance.

 
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