Clarification Regarding Spinal Fusion and Fixation Instrumentation
By: Amphion’s Training and Education Team
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Coding Clinic, 3rd Quarter, 2014, Page 30
Spinal Fusion & Fixation Instrumentation
The root operation fusion includes the insertion of rods, plates and screws for fixation. A separate code for insertion is not assigned.
Coding Clinic based this advice on the explanation of the root operation fusion which states “The body part is joined together by fixation device, bone graft, or other means.” ICD-10-PCS Guideline B3.1b states “Components of a procedure specified in the root operation definition and explanation are not coded separately.”
D3.1b
Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately.
Example: Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately. In a resection of sigmoid colon with anastomosis of descending colon to rectum, the anastomosis is not coded separately.
If you have any questions about this coding tip, please feel free to email us.
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