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Scenario Week of January 24, 2014:
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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:

Preoperative Diagnosis: Degenerative disc disease, L4-L5.

Postoperative Diagnosis: Degenerative disc disease, L4-L5.

Operations Performed

  1. Lumbar posterolateral arthrodesis, L4-L5
  2. Posterior lumbar interbody fusion, L4-L5 with Synthes PEEK interbody fusion cage spacer, 13 mm x2, at L4-5
  3. Local vertebral autograft


Estimated Blood Loss:400 ml

Operative Indications:The patient is a 54-year-old male presenting with a history of chronic, persistent low back pain which failed conservative management. Preoperative imaging studies revealed the above-noted abnormalities. After a detailed review of operative indications, methods, potential benefits, risks, and reasonable alternatives, the patient expressed understanding and elected to proceed with the procedure as noted above.

Description of Operation: Under satisfactory general anesthesia, the patient was placed prone on the Jackson table, pressure points and bony prominences were inspected and appropriately padded, and he was secured to the table. The back was then prepped and draped in the usual fashion. Intraoperative fluoroscopy was used to correlate and mark the cutaneous landmarks on the patient's skin with the underlying spinous processes. We infiltrated the skin in midline from these points and then used a #10 blade to incise in the longitudinal midline 4 cm through the skin, subcutaneous tissue, and lumbar fascia. Hemostasis was obtained with monopolar and bipolar electrocautery. We next did a subperiosteal dissection with periosteals and monopolar electrocautery, removing the spinal processes, lamina, and facets from L4 and L5 bilaterally. Retractors x 2 were placed into the wound to maintain visualization.

The L4-5 disc was exposed bilaterally. Posterior total discectomy was performed at L4-L5, using #15 blade, pituitary rongeurs, curettes, and a nerve hook to mobilize and remove disc material and curettage of cartilaginous endplates. A 15 blade was used to make a posterior retaining annulotomy. Using 13 mm paddle spacer, two 13 mm interbody fusion cage spacers were packed with locally obtained morselized bone graft and then packed into the disc space taking care to countersink the cages anterior to the posterior cortices of L4 and 5. A spinal retractor was placed.

The posterolateral pedicle screw fixation was carried out in the following manner. The pedicle screw entry sites were chosen using standard landmarks and fluoroscopic guidance as needed. Cortical openings were created at these sites using a small burr. The pedicular tracts were then preliminarily prepared using a pedicle finder. They were probed and subsequently tapped employing fluoroscopic guidance as needed. Each site was "under tapped" and reprobed with satisfactory findings noted as above. Screws in the following dimensions were placed: 6.5 mm diameter screws were placed at all sites. At L5, 40 mm length screws were placed bilaterally, and at L4, 40 mm length screws were placed bilaterally with findings as noted above. The rod was then contoured to span from the L4 to the L5 screws on the right.

Through the same incision, the posterolateral elements bilaterally from L4 to L5 were prepared for fusion in routine fashion, and local vertebral autograft was placed in the posterolateral fusion beds as well as the vertebral autograft in the dorsal aspect of the L4-L5 facets in a routine fashion. A left-sided rod was appropriated, contoured, and placed to span between the L4 to L5 screws. Again, compression was placed across the L4-L5 segments, and the connections were fully secured. Thorough hemostasis was obtained after checking the construct closely and fluoroscopically. In addition, all pedicle screws were stimulated with findings of above threshold noted at all sites. Spacer snugness and positioning appeared satisfactory.

Tisseel and Gelfoam were placed. At this point the retractors were removed. The paraspinal musculature was closed with interrupted 0-Vicryl sutures. The fascia was approximated with multiple interrupted 0-Vicryl sutures. The subcutaneous tissue was closed with inverted 2-0 Vicryl sutures over a small Hemovac drain, and the skin was closed with subcuticular 4-0 Monocryl. Antibiotic ointment, Telfa gauze, and foam tape were applied. There were no complications and the patient remained hemodynamically stable throughout the procedure.

Please assign the correct ICD-9-CM and ICD-10-CM/PCS codes for the procedure above.

Coding Answers

ICD-9-CM Diagnosis and Procedure Codes

722.52 Degenerative disc disease

81.08 Lumbar and lumbosacral fusion of the anterior column, posterior technique

81.07 Lumbar and lumbosacral fusion of the posterior column, posterior technique

84.51 Insertion of interbody spinal fusion device

81.62Fusion or refusion of 2-3 vertebrae

80.51 Excision of intervertebral disc

77.79 Excision of other bone for graft, except facial bones


Referencing the ICD-9-CM index term Degeneration, intervertebral disc, lumbar, lumbosacral, leads to code 722.52. Review of the tabular list confirms that diagnostic code assignment.

The procedures performed were a combination of posterior interbody fusion of the anterior column in addition to a posterolateral fusion of the posterior column through a single posterior incision (through the back). This type of surgery is commonly referred to as a 360-degree fusion because both the anterior and posterior of the vertebra are fused by bone graft.

A posterior total discectomy was performed and is reported by code 80.51. The discectomy procedure may be reported, but the laminectomy and foraminotomies are part of the operative approach for the spinal fusion and should not be coded separately.

The discectomy was followed by anterior column interbody fusion, fusing the bodies of the adjacent vertebrae with the interbody device and autograft via the posterior approach (PLIF), reported with code 81.08. Interbody fusion places the bone graft between the vertebrae in the anterior portion of the spine, in the area previously occupied by the intervertebral disc, which was removed in preparation for the spinal fusion. The disc was removed, and the interbody device was placed between the L4 and L5 vertebrae to maintain spine alignment and disc height. Through the same incision, the posterolateral fusion is performed between the bony endplates of the vertebrae using pedicle screws and autograft and is reported with code 81.07. The posterior interbody fusion is reported separately from the posterolateral fusion because it is done at a different part of the vertebral interspace. Spinal fusion is classified by the anatomic portion (column) fused and the technique (approach) used to perform the fusion.

The fusion codes also include instructional notes to “Code also any: insertion of interbody spinal fusion device (84.51), synchronous excision of (locally) harvested bone for graft (77.70-77.79), the total number of vertebrae fused (81.62-81.64).”

Code 84.51 is, therefore, assigned for the interbody device, and code 81.62 as the fusion involved two vertebrae (one intervertebral space).

Code 77.79 Excision of bone for bone graft, other, should be assigned for the harvesting of the autologous bone graft.

ICD-10-CM Diagnosis and ICD-10-PCS Procedures Codes

M51.36 Other intervertebral disc degeneration, lumbar region

0SG00AJFusion of Lumbar Vertebral Joint with Interbody Fusion Device, Posterior Approach, Anterior Column, Open Approach

0SG0071 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior Approach, Posterior Column, Open Approach

0ST20ZZResection of Total Lumbar Vertebral Disc, Open Approach


Diagnosis code M51.36 is assigned per the ICD-10-CM index term Degeneration, intervertebral disc, lumbar region. There is no documentation of myelopathy or radiculopathy. Review of the tabular list confirms this code assignment.

In ICD-10-PCS, arthrodesis (fusion) is reported with root operation “Fusion” defined as “Joining together portions of an articular body part rendering the articular body part immobile.” The body part is joined together by fixation device, bone graft, or other means. Fusion procedures are, by definition, performed only on joints, with qualifiers specifying whether the fusion uses anterior or posterior approach, and whether the anterior or posterior column of the spine is fused.

According to ICD-10-PCS Guideline B3.10a: “The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (i.e. thoracic). There are distinct body-part values for a single vertebral joint and for multiple vertebral joints at each spinal level.

Example: Body part values specify Lumbar Vertebral Joint, Lumbar Vertebral Joints, 2 or More, and Lumbosacral Vertebral Joint.”

Further instruction is provided by Guideline B3.10c: “Combinations of devices and materials often are 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 inter-body fusion device is used to render the joint immobile (alone or containing other material, such as a bone graft), the procedure is coded with the device value Interbody Fusion Device.
  • If 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, inter-body fusion device containing morselized bone graft is coded to the device Inter-body Fusion Device.

    Fusion of a vertebral joint using a bone dowel inter-body fusion device made of cadaver bone and packed with a mixture of local morselized bone and demineralized bone matrix is coded to the device Interbody Fusion Device.”

    If using the ICD-10 index, begin with the term Arthrodesis, which leads to the anatomical region under the table in the medical and surgical section, lower joints, fusion. The lower joints of the body are grouped in this column.

    For the posterior lumbar interbody fusion with an interbody fusion device via open posterior approach, anterior column (vertebral interspace), the appropriate code is 0SG00AJ: 0 Medical Surgical S Lower Joints G Fusion 0 Lumbar Vertebral Joint 0 Open A Interbody Fusion Device J Posterior Approach, Anterior Column

    For the posterolateral fusion, via open posterior approach, posterior column, using autograft, the code assigned is 0SG0071: 0 Medical Surgical S Lower Joints G Fusion 0 Lumbar Vertebral Joint 0 Open 7 Autologous Tissue Substitute 1 Posterior Approach, Posterior Column

    The discectomy procedure is coded in the same manner. Using the index, reference the term Discectomy, which will lead you to the choice of Excision for a partial discectomy or Resection for a total/complete discectomy. Lumbar spine is classified as Lower Joints in the medical and surgical section. The appropriate code is 0ST00ZZ. 0 Medical Surgical S Lower Joints T Resection 2 Lumbar Vertebral Disc 0 Open Z No Device Z No Qualifier

    The locally obtained autologous graft is not reported as it was obtained from the same body part. According to ICD-10-PCS Guideline B3.9: “if an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.”

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