The Business of Spine Coding Handbook For Spine Surgery 2015

Transcription

1 The Business of Spine Coding Handbook For Spine Surgery

2 The following Coding Concept Resource is not to be considered a replacement for the Current Procedural Terminology (CPT) book or the International Classification of Diseases 9 th Revision- Clinical Modification (ICD-9-CM) book. It is designed simply as a resource to help you get a handle on it. Always refer back to the full Current Procedural Terminology (CPT) book when coding. Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listing are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. International Classification of Diseases 9 th Revision-Clinical Modification (ICD-9-CM) is copyright 2014 OptumCoding. All Rights Reserved. 2

3 Table of Contents Procedural Codes DECOMPRESSION CODES... Anterior Decompression... Discectomy... Transoral Approach.. Corpectomy... Corpectomy for Lesion... Posterior Decompression... Laminotomy/Discectomy... Laminoplasty... Laminectomy... Laminectomy for Excision of Lesion other than Herniated Disk... Extracavitary Decompression... Lateral Extracavitary Approach for Extradural Exploration/Decompression... DURAL REPAIR.... ARTHROPLASTY... FUSION CODES... Anterior Fusion... Posterior Fusion... Extracavitary Fusion... Exploration of Fusion... Pre-Sacral Fusion... Instrumentation Anterior Posterior Interbody Implants (Anterior or Posterior) Removal/Reinsertion (Anterior or Posterior) Bone Grafts Bone Marrow Aspiration SPINAL DEFORMITY Intraspinous/Intrafacet Procedures OSTEOTOMY/EXCISION OF BONE Excision Osteotomy MISCELLANEOUS CODES Fracture Tongs/Halo Vertebroplasty Kyphoplasty Annuloplasty Incision & Drainage Infection Biopsy Neurostimulators Bone Growth Stimulators Imaging Unspecified Procedure Code Appendix A: Modifiers 16 Appendix B: Category III Codes: T Codes 17 Appendix C: Diagnosis Codes 19 Appendix D: Terminology

4 Procedural Codes DECOMPRESSION CODES Anterior Decompression Discectomy Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace (Do not report in conjunction with 22554, even if performed by separate providers. To report anterior cervical discectomy and interbody fusion at the same level during the same session use ) Cervical, each additional interspace (Do not report in conjunction with 22554, even if performed by separate providers. To report anterior cervical discectomy and interbody fusion at the same level during the same session use )Use in conjunction with Discectomy, anterior, thoracic, single interspace Thoracic, each additional interspace. Transoral Approach Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion Requiring splitting of tongue and/or mandible (including tracheostomy) Corpectomy for Spinal Condition Vertebral corpectomy (vertebral body resection), cervical, single segment. Partial or complete corpectomy, with decompression of spinal cord and/or nerve root(s) Cervical, each additional segment Vertebral corpectomy (vertebral body resection), thoracic, single segment Thoracic, each additional segment Vertebral corpectomy (vertebral body resection), thoracolumbar approach, lower thoracic or lumbar, single segment Each additional segment Vertebral corpectomy (vertebral body resection), transperitoneal or retroperitoneal approach, lower thoracic, lumbar or sacral, single segment Each additional segment Corpectomy for Intraspinal Lesion Vertebral corpectomy (vertebral body resection), extradural, cervical, single segment. Partial or complete corpectomy for excision of intraspinal lesion Extradural, thoracic, by transthoracic approach, single segment Extradural, thoracic, by thoracolumbar approach, single segment Extradural, lumbar or sacral by transperitoneal or retroperitoneal approach, single segment Each additional segment Vertebral corpectomy (vertebral body resection), intradural, cervical, single segment Intradural, thoracic by transthoracic approach, single segment Intradural, thoracic by thoracolumbar approach, single segment Intradural, lumbar or sacral by transperitoneal or retroperitoneal approach, single segment Each additional segment 4

5 Posterior Decompression Laminotomy/Discectomy Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar Each additional interspace, cervical or lumbar 0274T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic 0275T Lumbar Laminotomy, (hemilaminectomy), re-exploration, cervical (unilateral), single interspace, with decompression of nerve root, including partial facetectomy, foraminotomy and/or discectomy Each additional interspace, cervical Laminotomy, (hemilaminectomy), re-exploration, lumbar, (unilateral), one interspace Each additional interspace, lumbar Transpedicular approach, thoracic, single segment, with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc) Transpedicular lumbar, single segment, including transfacet or lateral extraforaminal approach. (e.g. herniated intervertebral disc) Each additional segment, thoracic or lumbar Costovertebral approach, thoracic, single segment, with decompression of spinal cord or nerve root(s), (e.g., herniated intervertebral disk) Each additional segment Laminoplasty Laminoplasty, cervical, two or more vertebral segments, with decompression of the spinal cord Laminoplasty, cervical, with reconstruction of the posterior bony elements, including the application of bridging bone graft and non-segmental fixation devices (e.g., wire, suture, miniplates), when performed 5

6 Laminectomy Laminectomy, cervical, one or two vertebral segments, with exploration and/or decompression of spinal cord and/or cauda equina, but without facetectomy, foraminotomy or discectomy, (spinal stenosis) Thoracic, one or two vertebral segments Lumbar, one or two vertebral segments, except for spondylolisthesis Sacral Laminectomy, lumbar (Gill type procedure), with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve root for spondylolisthesis Laminectomy, cervical, more than two segments, with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (spinal stenosis) Thoracic, more than two segments Lumbar, more than two segments Laminectomy, cervical, single segment, including facetectomy and foraminotomy (unilateral or bilateral) with decompression of spinal cord, cauda equina and/or nerve roots(s), (e.g., Spinal or lateral recess stenosis) Thoracic, single vertebral segment Lumbar, single vertebral segment Each additional segment: cervical, thoracic or lumbar. 6

7 Laminectomy for Excision of Lesion other than Herniated Disk Laminectomy, cervical, for excision of occlusion of arteriovenous malformation of spinal cord Thoracic Thoracolumbar Laminectomy, extradural, cervical, for excision or evacuation of intraspinal lesion other than neoplasm Thoracic Lumbar Sacral Laminectomy, intradural, cervical, for excision of intraspinal lesion other than neoplasm Thoracic Lumbar Sacral Laminectomy, extradural, cervical, for biopsy/excision of intraspinal neoplasm Thoracic Lumbar Sacral Extramedullary, intradural, cervical Thoracic Lumbar Sacral Intramedullary, intradural, cervical Thoracic Thoracolumbar Combined extradural-intradural lesion, any level Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure 7

8 Lateral Extracavitary Decompression Lateral Extracavitary Approach for Extradural Exploration/Decompression Vertebral corpectomy thoracic, lateral extracavitary approach, partial or complete corpectomy with decompression of spinal cord and/or nerve root(s) (e.g., for tumor or retropulsed bone fragments), single segment Lumbar, single segment Thoracic or lumbar, each additional segment Dural Repair Repair of dural/celebrospinal fluid leak, not requiring laminectomy With laminectomy Dural graft, spinal Arthroplasty-Artificial Disc Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); cervical, single interspace Second level; cervical +0375T Cervical; three or more levels Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace; lumbar, single interspace +0163T each additional interspace, lumbar Revision including replacement of total disc arthroplasty (artificial disc), anterior approach; cervical, single interspace +0098T each additional interspace, cervical Revision including replacement of total disc arthroplasty (artificial disc), anterior approach; lumbar, single interspace +0165T each additional interspace, lumbar Removal of total disc arthroplasty (artificial disc), anterior approach; cervical, single interspace T each additional interspace, cervical Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar +0164T each additional interspace, lumbar 0202T Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine 8

9 FUSION CODES Anterior Fusion Arthrodesis, C1-C2 (atlas-axis), anterior transoral or extraoral technique, with or without excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C cervical below C2, each additional interspace Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C Thoracic Lumbar Each additional interspace Posterior Fusion Arthrodesis, craniocervical, posterior technique Arthrodesis, C1-C2, posterior Arthrodesis, cervical below C2, posterior or posterolateral, single level Thoracic, with lateral transverse technique, when performed Lumbar, with lateral transverse technique, when performed Each additional vertebral segment Arthrodesis, lumbar, posterior interbody technique, single interspace, including laminectomy and/or discectomy to prepare interspace (other than for decompression) Each additional interspace Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy (other than for decompression), single interspace, and segment; lumbar Each additional interspace and segment, lumbar Lateral Extracavitary Fusion Arthrodesis, thoracic, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression) Lumbar Thoracic or lumbar, each additional vertebral segment Exploration of Fusion Exploration of spinal fusion Pre-Sacral Fusion Pre-sacral interbody fusion with posterior instrumentation, L5-S1 interspace +0309T L4-L5 interspace 0195T +0196T L4-L5 Pre-sacral interbody fusion, without instrumentation, L5-S1 interspace Arthrodesis, sacroiliac joint, percutaneous or minimally invasive, with image guidance, includes obtaining bone graft when performed and placement of transfixing device Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed. 9

10 INSTRUMENTATION Anterior Anterior instrumentation, 2-3 vertebral segments to 7 vertebral segments or more vertebral segments Posterior Posterior non-segmental instrumentation. (e.g., single Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) Internal fixation by wiring of spinous processes Posterior segmental instrumentation, 3 to 6 segments. (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires) to 12 vertebral segments or more vertebral segments Pelvic fixation other than sacrum Interbody Implants (Anterior or Posterior) Application of intervertebral biomechanical device(s) (e.g., synthetic cages(s), methylmethacrylate) to vertebral defect or interspace. (List separately in addition to code for primary procedure) Removal/Reinsertion (Anterior or Posterior) Reinsertion of spinal fixation device Removal of posterior non-segmental instrumentation Removal of posterior segmental instrumentation; e.g. pedicle screws at several levels Removal of anterior instrumentation Bone Grafts Allograft: morselized or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) Allograft: structural, for spine surgery only (List separately in addition to code for primary procedure) Autograft: (includes harvesting the graft); local (ribs, spinous process, or laminar fragments); obtained from same incision Autograft: Morselized, through separate skin or fascial incision Autograft: Structural Bicortical or tricortical (through separate skin or fascial incision) Bone Marrow Aspiration Bone marrow, aspiration only 10

11 Spinal Deformity Arthrodesis, posterior for spinal deformity, up to 6 vertebral segments, with or without cast to 12 vertebral segments or more vertebral segments Arthrodesis, anterior for spinal deformity, 2 to 3 vertebral segments, with or without cast to 7 vertebral segments or more segments Kyphectomy, circumferential exposure of spine and resection of vertebral segments(s) (including body and posterior elements); single or 2 segments or more segments Intraspinous/Intrafacet Procedures 0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices(s) single level; cervical 0220T Thoracic 0221T Lumbar +0222T Each additional vertebral segment 0171T Insertion of posterior spinous process distraction device; lumbar; single level +0172T Each additional level 11

12 OSTEOTOMY/EXCISION OF BONE Excision for Intrinsic Bony Lesion Partial excision of posterior vertebral component (e.g., spinous process, lamina or facet), cervical, single vertebral segment Thoracic Lumbar Each additional segment Partial excision of vertebral body, cervical, single vertebral segment, without decompression of spinal cord or nerve root(s) Thoracic Lumbar Each additional segment Osteotomy Osteotomy of spine, posterior or posterolateral approach, three columns, (e.g., PSO) thoracic, one vertebral segment Lumbar Each additional segment Osteotomy of spine, posterior or posterolateral approach, (e.g. Smith Peterson) cervical, one vertebral segment Thoracic Lumbar Each additional segment Osteotomy of spine, including discectomy, anterior approach, (e.g. Smith Peterson) cervical, single vertebral segment Thoracic Lumbar Each additional segment 12

13 Miscellaneous Fracture Closed treatment of vertebral process fracture Closed treatment of vertebral body fracture w/o manipulation requiring casting or bracing Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction Open treatment and/or reduction of odontoid fracture(s) and/or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting With grafting Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar Cervical Thoracic Each additional fractured vertebra or dislocated segment Tongs/Halo Application of cranial tongs, caliper or stereotactic frame, including removal Application of halo, including removal; cranial Vertebroplasty: Vertebral Body, Embolization or Injection Percutaneous vertebroplasty (bone biopsy included when performed), one vertebral body, unilateral or bilateral injection; inclusive of all imaging guidance; cervicothoracic lumbosacral Each additional cervicothoracic or lumbosacral vertebral body Kyphoplasty Percutaneous vertebral augmentation, including cavity creation using mechanical device, one vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic lumbar Each additional thoracic or lumbar vertebral body 13

14 Annuloplasty Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral, including fluoroscopic guidance; single level One or more additional levels Incision and Drainage Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic lumbar, sacral, or lumbosacral Infection Incision and drainage, complex, postoperative wound infection Biopsy Biopsy, muscle; superficial deep percutaneous needle Biopsy, bone, trocar, or needle: superficial (eg, spinous process, ribs, femur) deep (eg, vertebral body, femur) Biopsy bone, open; superficial (eg, ilium, sternum, spinous process,) deep (eg, humerus, ischium, vertebral body, femur) Biopsy, vertebral body, open; thoracic cervical or lumbar Neurostimulators Percutaneous implantation of neurostimulator electrode array, epidural Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Revision, including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed T 0283T 0284T 0285T Revision including replacement of spinal neurostimulator electrode plate/paddles(s) placed via laminotomy or laminectomy, including fluoroscopy Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Revision or removal of implanted spinal neurostimulator pulse generator or receiver Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous, cervical, thoracic or lumbar, for trial, including removal at the conclusion of trial period Permanent, implantation of neurostimulator with implantation of a pulse generator Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed 14

15 Bone Growth Stimulators Imaging Electric stimulation to aide in bone healing; Non Invasive Invasive (operative) Removal of implant, deep (e.g., buried wire, pin screw, metal band and, nail, rod or plate) Microsurgical techniques, requiring use of operating microscope Fluoroscope; up to 1 hour physician time Stereotactics Unspecified Procedure Codes Unlisted procedure, nervous system Unlisted procedure, spine 15

16 Appendix A: Modifiers 22 Increased Procedural Services: When the service(s) provided is greater than that usually provided for the listed procedure, it may be identified by adding a modifier 22 to the usual procedure code. A report may also be appropriate. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding a modifier 50 to the appropriate code. 51 Multiple Procedures: When multiple procedures, other than E/M services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). 52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced. 53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. 59 Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. 62 Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. 80/82 Assistant Surgeons: Surgical assistant services may be identified by adding modifier 80 or 82 to the usual procedure number(s). Use 82 modifier if a residency program is in place or 80 modifier if there is no residency program in place. 16

17 Appendix B: Category III Codes: T-Codes 0171T +0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace; cervical. (List separately in addition to code for primary procedure) +0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace; cervical +0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace; lumbar. Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level +0172T each additional level. 0195T 0196T 0200T 0201T 0202T 0219T 0220T 0221T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed: L5-S1 interspace L4-L5 interspace Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices(s) single level; cervical thoracic lumbar +0222T each additional vertebral segment 0274T 0275T 0282T 0283T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic lumbar Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period permanent, with implantation of a pulse generator 17

18 0284T 0285T Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed +0309T Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace 0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); cervical, 3 or more levels 18

19 Appendix C: Diagnosis Codes Late Effects of Infectious and Parasitic Diseases Late effects of other and unspecified infectious and parasitic diseases Neoplasms Malignant neoplasm of bone and articular cartilage; Vertebral column, excluding sacrum and coccyx Malignant neoplasm of bone and articular cartilage; sacrum and coccyx Malignant neoplasm of Spinal Cord Malignant neoplasm of other specified sites of the nervous system Secondary malignant neoplasm of other parts of nervous system Secondary malignant neoplasm of bone and bone marrow Secondary malignant neoplasm of other specified sites Benign neoplasm of bone and articular cartilage; vertebral column, excluding sacrum and coccyx Benign neoplasm of bone and articular cartilage; pelvic bones, sacrum and coccyx Neoplasm of uncertain behavior of bone and articular cartilage Neoplasm of uncertain behavior of other specified sites Neoplasms on unspecified nature; Bone soft tissue and skin Neoplasms on unspecified nature; Other specified sites Neoplasms on unspecified nature; Site unspecified Instability Instability, other joint derangement, not elsewhere classified, other specified sites NEC Other and unspecified disorders of joint; site unspecified Other and unspecified disorders of back; Instability, lumbosacral; disorders of the sacrum Spondylosis Cervical Spondylosis without Myelopathy Cervical Spondylosis with Myelopathy Thoracic Spondylosis without Myelopathy Lumbar Spondylosis without Myelopathy Thoracic or Lumbar Spondylosis with Myelopathy Thoracic region Lumbar region Spondylosis of unspecified site, without mention of Myelopathy Spondylosis of unspecified site, with mention of Myelopathy 19

20 Displacement/Herniation Displacement of cervical intervertebral disc without Myelopathy Displacement of Lumbar intervertebral disc without Myelopathy Displacement of Thoracic intervertebral disc without Myelopathy Displacement of intervertebral disc, site unspecified without myelopathy Degeneration of intervertebral disc, site unspecified Intervertebral disc disorder with Myelopathy; cervical region Intervertebral disc disorder with Myelopathy; thoracic region Intervertebral disc disorder with Myelopathy; lumbar region Degenerative/Degeneration Degeneration of cervical intervertebral disc; degenerative disc disease Degeneration of thoracic or thoracolumbar degenerative disc disease Degeneration of lumbar or lumbosacral degenerative disc disease Postlaminectomy Syndrome Postlaminectomy syndrome, cervical region Postlaminectomy syndrome, thoracic region Postlaminectomy syndrome, lumbar region Disc Disorder Other and unspecified disc disorder; cervical region Other and unspecified disc disorder; thoracic region Other and unspecified disc disorder; lumbar region Stenosis Spinal Stenosis in cervical region Spinal Stenosis in thoracic region Spinal Stenosis in lumbar region 20

21 Radiculitis/Radiculopathy Brachial neuritis or radiculitis NOS, cervical Neuralgia, neuritis, radiculitis, unspecified Pain & Radiculitis Cervicalgia; pain cervical spine Brachial neuritis or radiculitis NOS Ossification of posterior longitudinal ligament in cervical region Pain in the thoracic spine Lumbago; lumbar pain Sciatica Thoracic or lumbosacral neuritis or radiculitis, unspecified Backache, unspecified Disorders of sacrum Synovial cyst, unspecified Hypermobility syndrome Rheumatism, unspecified and fibrositis Myalgia and myositis, unspecified Disorders Osteoporosis Cyst of bone (localized); unspecified 21

22 Fractures Pathologic fracture; unspecified site Pathologic fracture of vertebrae Malunion of fracture Non-union of fracture; pseudoarthrosis Fracture of vertebral column without mention of spinal cord injury, cervical level, unspecified level Cervical, open *** For & 805.1, you must add the 5th digit which is the level at which the fracture has been noted; for example, closed fracture at C4 = *** Dorsal [Thoracic], closed Dorsal [Thoracic], open Lumbar, closed Lumbar, open Sacrum and coccyx, closed Sacrum and coccyx, open Unspecified, closed Unspecified, open Kyphosis Adolescent postural kyphosis Kyphosis (acquired) (postural) Kyphosis due to radiation Kyphosis, postlaminectomy Other Lordosis (acquired) (postural) Scoliosis Scoliosis (and kyphoscoliosis), idiopathic Other Curvature of spine, unspecified Kyphosis Other curvatures of spine Unspecified curvature of spine 22

23 Spondylolisthesis Acquired Spondylolisthesis Spondylolysis, lumbosacral region Spondylolisthesis Absence of vertebra, congenital Sprain/Strain Sprain/strain of lumbosacral Sprain/strain of neck Sprain/strain of thoracic Sprain/strain of lumbar Post-Op Mechanical Complication of internal orthopedic device, implant, and graft Mechanical complication of other specified prosthetic device, implant or graft due to other implant and internal device, not elsewhere classified Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft Disruption of external operation wound Infected postoperative seroma Other postoperative infection Non-healing surgical wound V45.4 Arthrodesis status V45.89 Post-surgical status, other 23

24 Appendix D: Terminology A vertebral segment describes the basic constituent part into which the spine is divided. It represents a single complete vertebral bone with its associated articular processes and laminae. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies which contain the intervertebral disc and the nucleus pulposus, annulus fibrosus and two cartilagenous endplates. Segmental instrumentation is defined as fixation at each end of the construct and at least one additional interposed bony attachment. Non-segmental instrumentation is defined as fixation at each end of the construct and may span several vertebral segments without attachment of the intervening segments. 24