AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2013 Issue 3; Ask the Editor

360-Degree Spinal Fusion

A patient diagnosed with stenosis and degenerative spondylolisthesis underwent a 360-degree fusion. The provider documented Crescent PEEK interbody device, locally harvested autograft bone, some allograft bone, and bone morphogenic protein (BMP) were inserted into the disk space and maneuvered into the anterior third of the disk space. The space was packed primarily with autograft. Transfacet lumbar interbody fusion was completed. Pedicle screws were placed on the left using image guidance. Left transverse process fusion L4-L5 was performed with placement of harvested autograft bone and allograft morselized chips were supplemented posteriorly. Attention was directed to the anterior side using C-arm image intensifier to assist with confirming the position on the right. An incision was made to midline on the right and carried down to the fascia. PAK needle with image guidance penetrated the pedicle and body of L4. The same process was done at L5. Sextant rod was rotated in position, torqued, then released and removed. Sextant screws and Pedicle screws were in excellent position bilaterally. What is/are the correct code(s) for the fusion portion of the 360-degree fusion? ...

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