AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Issue 2; Ask the Editor

Decompression of Spinal Cord and Placement of Instrumentation

The health record documentation states that the patient underwent laminectomy C3 through C7, decompression of the spinal cord, placement of posterior instrumentation and spinal fusion, due to cervical spondylosis. After decompression of the spinal cord, lateral mass screws were placed from C3-C6 bilaterally with connecting rods. Would placement of instrumentation be coded as a pedicle based stabilization device? What device value is assigned for the spinal fusion? Would the decompression of the spinal cord be coded separately or is it considered inherent to the total surgery? ...

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