All right, welcome, everyone. My name is Owechua Dogwood to this module on basic lumbar spinal coding. My hope today is to discuss, you know, basic pathologies that we care for as spinal surgeons or as neurosurgeons, as well as an algorithm for how to think about coding in a way that hopefully this sticks. So let's start with one of the common lumbar diagnoses that we see, lumbago, spondylolisthesis, radiculopathy, stenosis, spondylolisthesis, kyphosis, flat back, and instability. These are all things that we see in our practices week in, week out. As we start this module, it's very important to keep in mind the ICD-10 comprehensive book on diagnoses, both from a neurological standpoint, as well as from a musculoskeletal standpoint. Very important to keep in mind that chapter six of this book handles disorders of nervous system and chapter 13, diseases of the musculoskeletal system and connective tissue. So you may have to toggle between two chapters. And chapter 19 and 20 covers things like trauma. So let's start with a common problem, spondylolisthesis, these are the M43 codes. If it's an unspecified site, use the M43.1 code. If it's been between L1 and L5, use M43.16. And if it's between L5 and L7, the lumbar sacral region, use M43.17. Looking at this figure here, this patient has an L4, L5 spondylolisthesis. So this falls squarely into the M43.16 code. When you look at this image here, the spondylolisthesis is a parsed defect and a spondylolisthesis. This is at L5, S1. So you're going to use your diagnosis code of M43.17. What about things like lumbago? This is a patient with spondylolisthesis with spondylosis or with radiculopathy. In this case, you use the M47.2 codes. Again, just like the prior slides, you think about the region where this is located. So if it's an unspecified site, use the M43.20 code. If it's between L1 and L5, use the M47.26 codes. And if it's in the lumbar sacral region, use the M47.27 codes. In this case, this patient has a spondylosis mostly isolated to the L4, L5 region, so use the M47.26 diagnosis codes. Let's talk about spinal stenosis. This is going to be the M48 codes. In this case, it's very important that you think about whether or not the patient has spinal stenosis with neurogenic claudication or spinal stenosis without neurogenic claudication. If a patient presents with spondyloma stenosis without neurogenic claudication, that's the M48.061 codes. Lumbar stenosis with neurogenic claudication, that's the M48.062 codes. And in lumbar stenosis isolated to the lumbar sacral region, use the M48.07 codes. In this case, this patient has a lumbar stenosis with neurogenic claudication located at L3, L3 or 4. And in this case, you're going to use the M48.062 codes. Scoliosis is another problem that we all care for. These are the M41 codes. If it's a juvenile idiopathic scoliosis, you use M41.1 code. If it's an adolescent, M41.12 codes. And if it's an idiopathic, M41.2 codes. Where they're located, you should also think about it. In thoracolumbar junction, that's M41.25. If it's in the lumbar region, M41.26. And if it's lumbar sacral, M41.27. Flat back, another common problem that we see and take care of in spinal surgeons. This is going to be the M40.3 codes. If it's the thoracolumbar region, you think about the M40.35 codes. If it's in the lumbar region, the M40.36 code. And if it's in the lumbar sacral region, you think about the M40.37 code. Flat back syndrome. In this case, this is the M40.3 code, just like we discussed previously. In this case, this is isolated to the lumbar-lumbar sacral region. So you could use the M40.36 code for the lumbar or M40.37 for the lumbar sacral codes. The other series of codes we're going to talk about are the spinal instabilities. This is the M53.2X category of codes. Keep in mind that if it's located in the thoracolumbar region, that's the M43.2X5 code. If it's the lumbar region, M53.2X6 code. And if it's the lumbar sacral region, that's the .2X7 code. Okay, so basically a summary of some of the other diagnoses and some of the diagnoses that we've covered. Lumbar code, that's going to be the M54.4 codes. Lumbar spondylosis with radiculopathy, that is going to be the M47.26 codes. Lumbar spondylolisthesis, that is going to be the M43.16 codes. Lumbar spondylosis without radiculopathy, that's going to be the M48.812 codes. Flatback syndrome, that's going to be the M40.36 codes. Instability, the M53.2X6 codes. And then this is some of the other diagnoses that we discussed. It's very important as you think about these diagnoses to keep in mind where they occur and the region they occur because that influences the codes that you use. What are some common lumbar procedures? Microdiscectomies, laminectomies, transfrontal lumbar interbody fusion, single-level, multilevel, transverse interbody approaches, anterior lumbar interbody fusions, posterior column osteotomies, and anterior-posterior fusions. So generally, when I think about coding, I try to distill the procedure into its core elements. What are you trying to do? Well, you think about you're decompressing, you're instrumenting, you're grafting, and oftentimes you're performing an arthrodesis. So think about DIAD, decompression, instrumentation, arthrodesis, and grafting, okay? And if you break it down into those components, it's very easy to think about. In general, decompression codes are the 63000 codes, the arthrodesis codes are the 22000 codes, the instrumentation codes 22840, and then we'll talk about some other, 22840, 22842, 22843, and so on. And then the bone grafting codes, we're going to talk about in quite some detail as well. If you use microsurgical technique and you use the microscope, a floor-mounted microscope, you want to use the 69990 code. If you use computer-assisted neuro-navigation, it's 61783. Remember, to use this code, you have to dictate in your op-node exactly what you did. You looked at the CT scan, you measured the length of the pedicles prior to surgery, you then brought in the ORM, you took a spin, you went to the council, you planned your screw trajectories, and so on. All of that needs to be captured in order to use that 61783 code. It's very important as well for your coders that you use computer-assisted neuro-navigation for placements of implants. Very important. And then bone marrow aspirate by a separate incision, that's 20939 code. So when you're thinking about posterior instrumentation versus anterior instrumentation, these are some of the common codes that we use. Posterior instrumentation, you're thinking, are they segmental or are they non-segmental? So you have the 22840 codes, the non-segmental two points of fixation, and all the other points of fixation that you can see there, 22842, 22843, 22844, these cover multiple points of fixation. Anterior instrumentation codes, these are separate. The anterior instrumentation is very important. These are separate instruments. These are separate implants. So if you do a standalone anterior cervical discectomy infusion with integrated implants or integrated ALIF implants, it doesn't count for the anterior instrumentation. The plate has to be separate from the inner body. So you have the different codes, 22845, 22846, 22847, and we'll talk about some of these codes in more detail as we go on. You think about the inner body codes, some of the common ones that we use are the 22853 codes, and we'll talk about some of these other codes as we go on through the case. So you think about using posterior instrumentation, you're going to use some of the codes to the left. Anterior instrumentation, you're going to use some of the codes to the right, and then you have to talk about some of the inner body device and implants and that you use them, and we'll talk about that in the upcoming slides. For bone grafts, you have to think about the types of grafts that you use. Are you using a morselized allograft? In that case, that's going to be 20930. Most people use this when you're doing an arthrodesis. Are you using structural allograft? That's going to be 20931. Are you using autograft via the same harvesting, via the same incisions? So ribs, spinous processes, laminar fragments, that's 20936. You should code this for all your arthrodesis cases. If you're using autograft via a separate incision, so you're using an iliac crest graft via a separate incision, you might want to consider using 20937. And if you're harvesting autograft, structural, bicortical, tricortical autograft via a separate incision, that's 20938. Bone marrow aspirate, as I mentioned in the prior slide, that's going to be 20939. So what are the general principles of coding that I want you to keep in mind as we move forward through this? Remember the DIAC, decompression, arthrodesis, instrumentation, grafting. So choose a standalone code for your decompression and discectomy. Choose a standalone code for your arthrodesis. And then choose your add-on code for your instrumentation, grafting, and other procedures or adjuncts that you needed for the operation. So let's talk about some microdiscectomies. You're doing a single-level microdiscectomy. You're going to perform a hemilaminotomy with decompression of the nerve roots in the lumbar spine. So you're going to use 63030. For each additional inner space, you use 63035. If you are doing a redo, re-exploration, it's a bit more complex. You have to take a bit more bone. You have to dig through a little bit more scar. So use a different code. That's going to be the 63042. And if you're doing bilateral, use the modifier 51. So let's talk about the lumbar laminectomies. And these are lumbar laminectomies, bilateral media facetectomies, and foraminotomies for decompression of the nerve root. It's very important that you document that you perform not just the laminectomy, but you did the facetectomy and the foraminotomy unilaterally or bilaterally. At a single level, you use 63047. For each additional level, whether it's a cervical thoracic or lumbar spine, use 63048. So if you're doing a laminectomy, for instance, the cervical spine, which is beyond the scope of this, you use a different code. Thoracic spine, a different code. Lumbar spine, I use the 63047. But for each additional level, you use the 63048. But I also want to emphasize in this that this is a very comprehensive decompression. And you need to communicate that not only to your coders, but also to the third-party payers exactly what you did. So let's talk about some upholstery instrumentation. You know, we mentioned this term segmental versus non-segmental. So any implant that's spanning that has two points of fixation, independent of how long that is, those are non-segmental fixation. In that case, whether you're doing a C1, C2, or whether you're doing an old traditional herniated rod construct, you use the 22840. So this is a non-segmental instrumentation. 22841, this is basically internal spinal fixation by wiring of the spinal processes. You can bundle this when you use with other upholstery instrumentation codes. 22842, these are segmental instrumentation. This is spanning three to six vertebral segments. So you want to use the 22842 codes. 22843, this is spanning seven to 12 vertebral segments. And you want to use this code. Then 22845, this is for anterior instrumentation. This is spanning two to three vertebral segments. This is an add-on code, so you want to list separately in addition to the primary code. Very important for this is that this has to be a standalone implant. This has to be a separate implant. So if you look at the figure to the right, you see what appears to be an anterior lumbar interbody cage that has screws. It looks like an integrated system, so you cannot use this 2285 code here. This needs to be a separate implant in addition to the interbody device that you're using. OK, so in these cases, as I mentioned, these are integrated systems. You cannot use this plate here. You cannot use this code here. 22845, you can use it here. In this case, you can see that this patient appears to be an L5S1 anterior lumbar interbody fusion. This is a separate plate. If you look at the figure to the left, you have an expandable cage with a plate. You can use this because this is a separate standalone implant. So this is an appropriate use of this code when you're performing this procedure. OK, so 22840, posterior non-segmental instrumentation, two points of fixation. This could be, you know, T12L1. This could be an old traditional Harrington construct like this, two points of fixation. So you use the 22840. OK, 22842, three to six points of fixation. 22843, seven to 12 points of fixation. And then 22844, 13 or more points of fixation. The key here is the number of levels traversed, not the number of fixation points. So to go back with the examples that I gave, you really want to pay attention to the number of levels traversed, not the number of fixation points for the instrumentation. And here is segmental, example of segmental versus non-segmental. And here we talk about the anterior, some of the anterior approaches and the transverse approaches. 228, 22558, this is your traditional arthrodesis, anterior interbody technique, including minimal discectomy to prepare the interspaces where you typically code for your ALIF. And each additional level, you use the 22585. There's no code for the anterior lumbar, no CPT code for the anterior lumbar decompression. And that brings us to the end of this. We've talked about coding, hopefully in a stepwise fashion. We've talked about the instrumentation, and we've certainly talked about the arthrodesis. Thank you for your time.

lumbar spinal coding

diagnoses

procedures

ICD-10 comprehensive book

spondylolisthesis