Hi, everyone. It's nice to see you. I'm going to talk a little bit about advanced case-based lumbar coding. We'll begin by looking through some different cases, including anterior-posterior lumbar fusions, multilevel fusion, corpectomy, deformity cases, and help you through the coding for each of these different scenarios. When looking at basic spine coding, ICD-10 and CPT reveals that there are multiple different diagnoses under lumbar interventions. You would see interventions for a diagnosis of spondylolisthesis, stenosis, flat back deformity, and scoliosis. So the first case we're going to look at is an L5-S1 spondylolisthesis with a steep sacral slope. This is a 52-year-old woman who participates regularly in triathlons, who presents with progressively worsening bilateral radicular leg pain, left greater than right, has received transforaminal injections over the past four years with complete relief of symptoms, has had no benefit over the past year. On neurologic exam, the patient is intact throughout all muscle groups of the lower extremities, capable of walking on her heels and toes, decreased sensation of the dorsum of her left foot, and has a positive straight leg raise bilaterally. Here are her X-rays. You can see a grade 1 spondylolisthesis at L5-S1. On flexion extension, there appears to be some reduction or exaggeration of the spondylolisthesis depending on position. An MRI demonstrates severe neuroforaminal stenosis as well as on-passage nerve root stenosis as well. Here in a more detailed view, you can see the left L5 foramen and the right L5 foramen. You can also see the PARS defects present posteriorly. A high suspicion was maintained in order to justify a CT scan that demonstrates the PARS fracture in better detail. So the diagnosis here is spondylosis versus spondylolisthesis versus radiculopathy and instability. Which of these things are true? We look at our diagnosis codes and we start by picking under spondylolisthesis the lumbosacral region. We also have spondylolisthesis, lumbosacral region, radiculopathy, lumbosacral region, and instability at the lumbosacral region. Which one of these things should we consider is likely M43.07, M54.17, and M53.2x7? So the procedure performed is an anterior approach to the lumbar spine at L5-S1. A complete discectomy is performed with preparation of the end plates for inner body fusion. An inner body spacer with a retention screw is placed, repositioning prone for non-segmental instrumentation at L5-S1, bilateral gill laminectomies for decompression of the L5-S1 nerve roots, and posterior lateral fusions from L5 transverse process to the sacral ala. And you can see that here in the post-operative images demonstrating an L5-S1 alif and posterior spinal fusion. So the coding here is 22558-62, modifier 62 is important because of the presence of the assistant, sorry, co-surgeon, arthrodesis, anterior inner body technique, including minimal discectomy to prepare inner space other than for decompression. 22853-62 is the inner body spacer, which includes the retention screw, no separate plate was placed. And then allograft, which is 20930-62, allograft morselized replacement of osteopromotive material for spine surgery only. Now we think about the posterior approach, which is 63012, laminectomy with removal of abnormal facets and or pars articularis gill type procedure. 22612 captures the single level arthrodesis from the L5 transverse process to the S1 ala. And 22840 is the non-segmental instrumentation at L5-S1. And then the allograft 20936, one month post-op and six months post-op, the patient generates a fusion. The patient wants to start training in an Ironman. So here we have case number two is an L3-S1 360 decompression infusion, 65-year-old nurse with a history of axial back pain, neurogenic claudication, and radiculopathy, can no longer work because of symptoms. Non-focal neurologic exam, normal strength, normal sensation, cannot stand for more than five minutes, cannot sit for more than 10 minutes. Here are the images, suggest that the patient has multiple levels of spondylolisthesis, a mild coronal scoliosis, MRI demonstrates similar issues, including bilateral neuroforaminal stenosis and a spondylolisthesis at L3-4 and L4-5. The patient also obtained a spectroscopy image that demonstrates hyperintensity and fluorophore uptake at L3-4 and L5-S1 as demonstrated on these three images here. So we look at the diagnosis here at spondylolisthesis, M43.16, degenerative disc disease, M47, and then radiculopathy. So the procedure that was performed was an anterior approach for a two-level ALIF at L4-5 and L5-S1, an L3-4 TLIF, and pedicle screw implementation from L3-S1 with Smith-Peterson osteotomies at L3-4, L4-5, and L5-S1. So here are the final pictures. You see the two-level ALIF, the TLIF, and the Smith-Peterson osteotomies to reduce the spondys and achieve global segmental lordosis. So the appropriate coding for this procedure includes the 5-1 and 4-5 ALIF, that's 2-2-5-5-8, 2-2-5-8-5 for the additional level, 2-2-6-3-3 is the TLIF, 2-2-8-5-3 for peak inner body spacers at each one of these levels, 2-2-8-4-2 for segmental instrumentation at L3-S1, computer assisted navigation, the osteotomies, additional osteotomies, the posterior lateral fusion from L4-5 and L5-S1, 2-2-6-1-4 times 3, and then 2-0-9-3-0 and 2-0-9-3-6 for morselized allograft to morselized autograft. So here's some visual coding for you, 2-2-8-5-3 are the inner body spacer, 2-2-8-5-3 again, 2-2-5-8-5 for the ALIF and 2-2-5-5-8, and then you have the 2-2-6-3-3, which is the TLIF, and then you have the 2-2-8-4-2 and 6-1-7-8-3, the navigation for the posterior lateral fusion and posterior instrumentation, and then similarly, each of the codes describing the osteotomies that were completed, additional levels of fusion here. 2-0-9-3-0, 2-0-9-3-6 describes the autograft allograft used for bone infusion promotion. So here are the final codes. Now looking at a case of spinal deformity, we have a 76-year-old woman who presents with incapacitating axial back pain and right greater than left radicular pain. Patient with progressive decline, now dependent, unable to ambulate greater than 10 feet. My wife is not worth living like this. She has severe morbidity from her diagnosis. She's had three previous MIS spine procedures performed since 2011. At L2-3, she's had decompression, L3-4 decompression, L4-5 decompression, and she's being offered another decompression by her primary surgeon. These are her images that demonstrate flat back, anterolesthesis, coronal scoliosis. Here are the images in 2017. Here are flexion extension. Clearly, things have progressed. Her MRI, multiple levels of central and neuroforaminal stenosis. Her coronal scoliosis is about 24 degrees. She has a PILL mismatch of approximately 22 degrees. The diagnosis is degenerative scoliosis, flat back deformity, and lumbar stenosis with neurogenic claudication, M41.25 thoracolumbar, M41.26 lumbar, M41.27 lumbosacral. And so flat back syndrome gives us a breakdown of these ICD-10 codes this way. Similarly, when we look at lumbar and lumbosacral, these are the codes that we're going to use. So the surgery that was performed was a lateral approach to the spine at L2-3 and L3-4, a posterior approach to the lumbar spine, L1 to L5, an L4-5 T-lift, Smith-Peterson osteotomy at each of these levels, segmental instrumentation at L1-5 with computer-assisted navigation, posterior lateral fusion L1-5, and then L1-2, L2-3, L3-4, L4-5 arthrodesis. So L5-1 was left alone. Here you can see the images and the post-operative results. You can see pre-op versus post-op. And here are her coronal scoliosis pre-op versus post-op. And here's the coding, 22558 for the trans-soas approach and then the additional segment 22585, 22633 for the T-lift, 22853 for the peak spacers placed between L2-5, the segmental instrumentation 22842, computer-assisted navigation 61783, Smith-Peterson osteotomy 22214 primary code, and then the additional segments of osteotomies at 233445 as built here, and then additional levels of posterior lateral fusion in addition to the T-lift L1-2, L2-3, L3-4, and then morselized autograft. So here's a visual representation of it. You have the 22853, the 228585, and then you have the posterior instrumentation codes and the posterior lateral fusion codes, 22842, and then 61783. You want to put that navigation code right underneath the instrumentation code so that the payer knows that you used the navigation code for placement of the pedicle screw implants 22214, and then the additional 22216 times 3, and then the 22614 fusion, 22614 fusion, 22614 fusion, and the fusion at L4-5 is covered underneath your T-lift code here. And so the final codes here are what we talked about earlier, which is 22558 trans-SOAS L2-3, 22585 trans-SOAS again, and then you have your additional codes listed here. Now looking at spine fractures, thoracic fracture dislocation, sorry, 31-year-old man fell 20 feet off of a roof onto a sawhorse sustaining multiple injuries, complete spinal cord injury at T11, very bad image. T11-12 fracture dislocation, complete spinal cord injury. Here, the ICD-10 codes, injuries to the thoracic spine, injuries of the thoracic spinal cord, complete injury of the thoracic spinal cord, T11-12, incomplete injury of the thoracic spinal cord at T11-12, fall from height, slipping, falling, stumbling. So at the end of the day, we're going to say S24.114 and W13.2. So here's the procedure. Open reduction, internal fixation of thoracic fracture, placement of pedicle screws for segmental posterior instrumentation, computer-assisted navigation, arthrodesis, additional segments of arthrodesis, morselized allograft, autograft, and placement of a lumbar drain. Probably had a traumatic CSF leak and also reduced intrathecal pressures. So pre-op versus post-op, very good reduction in the fracture here and the posterolateral screw placement you can see here as well. And then the coding will be open reduction of thoracic fracture, 22327, 22842, placement of pedicle screws for segmental instrumentation, 61783, computer-assisted navigation for placement of pedicle screws, arthrodesis, T10-11, additional arthrodesis, T11-12, and T12-01, morselized allograft, morselized allograft, and placement of lumbar drain. So here's your visual coding. Here's your fracture dislocation. Realigning it gives you that open reduction internal fixation of a thoracic fracture, 22327. And then you have the visual coding of your posterior instrumentation. So here it's 22842, 61783, again, the navigation code. Then you have your 22610 and then 22614 and 14 for arthrodesis of each of those levels. And then obviously use of autograft and allograft, 20930 and 20936. So here are the codes. And then 22327, 22842, pedicle screws, 61783, and then the arthrodesis from each of these levels. The placement of the lumbar drain is 62272. So new technology, interspinous process distraction. So 53-year-old male, planar neurologic claudication, single-level lumbar stenosis, no abnormal motion on flexion and extension. Here you go. X-rays. Patient undergoes midline angioplasty. Here you go. X-rays. Patient undergoes midline approach to the lumbar spine, partial laminectomy, forward preservation of the spinous process, removal of thick ligamentum flavum, and placement of an intraspinous process distractor. So here you go. So what we have is that 0171T and 0172T were deleted in 2017. Here are the new codes, 22867, insertion of intralaminar interspinous process stabilization distraction device. Here are your work RVUs associated with it. And then if you did a second level here, the additional work levels. And it's associated with an open decompression. Now, if you insert the device without a decompression, it's seven RVUs, and it's 22869, insertion of intralaminar interspinous process stabilization device without open decompression or fusion, and then 22867. So patient presented for additional opinion, your clinic six months after surgery with persistent symptoms, and then probably got the definitive surgery here. And then L45 transforaminal lumbar interbody fusion with posterolateral fusion, L4 laminectomy partial L5, non-segmental instrumentation, a peak spacer, morselized allograft, and morselized autograft. Remember the 63047 with a modifier 59, a recent addition in the last several years to capturing the decompression work that is outside of the TLIF work. Thanks very much for your time today. Thank you.

advanced case-based lumbar coding

anterior-posterior lumbar fusions

multilevel fusion

corpectomy

deformity cases