AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2014 Issue 3; Ask the Editor

Spinal Fusion & Fixation Instrumentation

Coding Clinic, First Quarter 2013, pages 29-30, advised to assign code 0RG40A0, for interbody fusion of C7 and T1 with placement of Vectra Synthes plate and screws. Third Quarter 2013, pages 25-26, advised to assign codes 0SG0071 and 0SG00AJ for a 360-degree interbody and autologous bone graft spinal fusion with placement of pedicle screws. Some coders disagree with this advice and feel that the plates and screws used during spinal fusion should be coded separately, since different root operations are utilized. The procedure appears to meet guideline B3.2c (multiple root operations with distinct objectives are performed on the same body part). Please clarify whether a separate code is assigned for internal fixation/instrumentation (rods, screws, plates, etc.) used with spinal fusion. ...

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