This would be incorrect if the surgery is open where the surgeon dissects down to the level of the vertebra. Some coders wrongly assume that if a robot is issued, it is not open but a percutaneous endoscopic approach. The surgeon actually documented this as a procedure in the list on the operative report. One example is the Mazor Stealth edition. In some of the cases we reviewed, a robot was used during the anterior open interbody fusion. Please refer to the links in the References section below. If the documentation does not document clearly what the stereotactic navigation is being used with, the coder can query or ask to have physician education on the documentation of this procedure in its entirety. Both stereotactic navigation with 3D CT and separate fluoroscopy can be used on the same case. So coders must look for what imaging is used with the use of stereotactic navigation. In most cases, fluoroscopy is used in many of these surgeries, but not directly with the stereotactic navigation as the operative note excerpt above states with the 3D CT. Many times the surgeon uses the same type of guidance on both anterior fusions and posterior fusions.Ĭoders asked about the use of fluoroscopy, and if 7 th character F – With Fluoroscopy should be used.
#Ifactor biologic code#
This would be coded 8E0WXB G Computer Assisted Procedure of Trunk Region, with Computerized Tomography.ĪGAIN, if this is used on two separative operative procedure dates, the coder would report this code TWICE with the applicable date.
#Ifactor biologic registration#
After registration of the navigated instruments were performed, exposure was performed by Dr.-.” As the coder can see, the use of 3D CT was done with the stereotactic navigation. This was merged with the patient’s preoperative CT. An O-arm was brought in and a 3D CT spin was performed. Here is how it was written: Surgeon will list this in the Procedures Performed: “ Use of stereotactic computer assisted navigation” Within the operative note the coder will see: “A pin was placed in the left iliac crest. We found upon review that these surgeons were using stereotactic navigation WITH CT however coders were erroneously assigning “Z-No Qualifier” as the last character in the code. H – With Magnetic Resonance Imaging (MRI) This is code 8E0WXB- Computer Assisted Procedure of Trunk Region, with the last character value telling us what the stereotactic navigation was used with: In the cases we reviewed, most of the time, stereotactic navigation was used.
If both spinal nerves and spinal cord (such as thecal sac or central cord) are released, code both as these are separate body parts – see CC1Q2019 P.28. Sometimes the surgeon will list in the procedures that a decompression is to be done but the operative report may not document it. Key terms to look for are: Diagnoses such as stenosis, claudication or myelopathy Procedure terms such as: laminectomy, decompression, release of nerve or roots. Use root operation “Release” even if lamina or disc is excised because the coder must code for the objective, or intent, not how the surgeon does the procedure. Identify the level released – Cervical, Thoracic, Lumbar, Sacral and code ONCE per level release. If there is not documentation of total removal of the intervertebral disc, then code to root operation “Excision.”Ī decompression of a nerve root, spinal cord OR BOTH may or may not be done during a spinal fusion. Total vs Partial Removal of Intervertebral DiscĪs coders know, if the entire disc is removed, this is coded to “Resection” root operation for the site of the disc removal i.e., cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, lumbosacral. Also check to see if CT is being used with navigation. Again, there may be the use of stereotactic navigation in this procedure and if used, it should be coded. Then, two days later, a second surgery was done where the approach was posterior OPEN, dissecting down to the vertebra.
#Ifactor biologic full#
So coders must be sure to review BOTH operative reports for the full details of this procedure. In the cases we reviewed, two different surgeons worked on the case, one to perform the approach down to the intervertebral disc, and another surgeon did the actual laminectomy, and access to the interbody, disc removal and fusion. At times, anterior instrumentation may be done.
The interbody is accessed, disc is removed and interbody fusion device is placed. Many times robotics or a robot is used AND stereotactic navigation are used and both of these codes should be reported on this day. Sometimes this was an OLIF or Oblique Lateral approach which is an anterior approach. In many of the cases we reviewed, the surgeon performed an anterior OPEN approach dissecting down to the anterior spine.
Anterior Interbody Fusion and Posterior Fusion and Approaches
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