Neurosurgery Coding Alert

 The term “thoracic” is related to the patient’s chest.

If you’ve ever felt overwhelmed while trying to code spinal surgeries, you are not alone. The anatomical intricacies of a patient’s spinal condition are enough to stump even the most seasoned coder. If you aren’t familiar with the different sections of the spine, you could be jeopardizing your claims.

During the Virtual HEALTHCON 2020 presentation “Spinal Surgery Update 2020,” Lynn M. Anderanin, CPC, CPPM, CPC-I, CPMA, COSC, broke down the basics of spinal anatomy coding, lending some context to the sometimes confusing terms that characterize this tricky part of the body.

Read on to learn more.

Pinpoint Abbreviations for Spinal Anatomy

The best way to learn about spinal anatomy is first knowing the terms and body areas associated with each vertebral set. As a quick reference, Anderanin laid out this chart that she uses to introduce coders to spinal anatomy:

 The information in the above table can be an invaluable resource when making sense of encounter notes.

Example 1: The notes indicate that the provider treated vertebrae T1, T2, and T3 in the patient’s lumbar area. Something’s wrong with these notes, as the T spinal segments are thoracic, not lumbar.

Example 2: The notes indicate that the provider treated two coccyx vertebrae in the patient’s tailbone area. These notes make anatomical sense.

Take it from the top: It is useful to know the order that the vertebrae fall along the spine as well, to make sure that you count and catalog segments and interspaces correctly. From the cervical (neck) area to the sacrum (pelvis) area, the abbreviations are listed thusly:

• C1-C7
• T1-T12
• L1-L5
• S1-S5.

This information could be a vital lifeline when choosing codes because it can help you deduce if the encounter notes make sense. If notes indicate that the surgeon treated vertebral discs C2-S1, you might want to check with the provider. This seems a medically unlikely (and huge) area of the spine to treat — it indicates that the surgeon treated nearly 25 vertebrae.

Differentiate Between Vertebral Segments and Interspaces

Coders need solid knowledge of the differences between vertebral segments and vertebral interspaces, Anderanin says. Without this info, coding spinal surgeries isn’t going to be easy.

Vertebral segment: This term describes the basic parts into which the spine is divided. The word “segment” represents one complete vertebra and includes any related laminae and articular processes, Anderanin explains.

Vertebral interspace: The non-body compartments between vertebrae are interspaces. The intervertebral disc is in the interspace, as are the nucleus pulposus, annulus fibrosus, and a pair of cartilaginous endplates, Anderanin says.

For example, the notes indicate that the surgeon treated vertebrae L1-L3. Just from this information, you can glean the following if you have spinal anatomy smarts:

• The surgeon treated three vertebral segments: L1, L2, L3.
• The surgeon treated two interspaces: between L1-L2 and L2-L3.

In spinal surgery, you will have a primary code, and additional levels are normally reported with an add-on code, Anderanin says. So, it is important to know if you are looking at a vertebral segment or interspace because that information will determine how many of each you are going to code when talking about multiple levels.

When she performs surgery coding audits for clients, the number one problem she sees is coding with the wrong number of levels, whether it’s interspace or vertebral segments, according to.

Coding example: To illustrate her point on anatomy, Anderanin ran the group through some clinical examples to show how to count vertebral segments and interspaces. Here is one of those examples:

The patient has herniated disc L5-S1. The surgeon placed the patient in prone position and made an incision to access the spine. Fluoroscopy was used to confirm surgical level. The surgeon used a knife to incise the disc, freeing the S1 exiting left nerve root and performing a microdiscectomy.

For this encounter, you should report 63030 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar). The surgeon treated a single interspace during this procedure: L5-S1.

Editor’s note: Want more great info like this? You can now register for the upcoming 2020 HEALTHCON regional conferences: https://www.aapc.com/medical-coding-education/conferences/. Also, early bird registration is open for 2021 HEALTHCON in Dallas. Visit www.aapc.com for more info.