Below is an example of an anterior cervical spinal fusion coded using the current ICD-9-CM codes as well as the future ICD-10-CM and ICD-10-PCS codes that would be assigned for this procedure.

Preoperative diagnosis: Cervical spondylosis with myelopathy

Postoperative diagnosis: Same

Procedure:                            
1.      Anterior cervical discectomy with spinal cord decompression, C3-4, C4-5

2.      Anterior interbody fusion, C3-4, C4-5

3.      Insertion of interbody device. C3-4, C4-5

4.      Anterior segmental instrumentation, C3, C4, and C5

Anesthesia: General

Procedure description:  The patient was brought to the operating room where general anesthesia was induced. Antibiotics were given to prevent infection, and bolsters were placed between the scapulae. The shoulders were taped, and the left neck was prepped and draped in routine sterile fashion. The C4 vertebral body was identified and marked. Transverse incision from the midline out to the sternocleidomastoid was made, and bleeding was controlled with electrocautery. The platysma was divided and undermined superiorly and inferiorly. The interval between the strap muscles and medial structures and the carotid sheath laterally was then bluntly dissected. The spine was encountered at this point and hand-held retractors were used to elevate the longus coli muscles bilaterally from C3-C5. A self-retaining retractor was placed at C3-4, and imaging was used to verify the level. Caspar screw post retractors were then placed to distract the C3-4 disc. Anterior osteophyte was resected, and discectomy was undertaken with a combination of rongeurs and pituitaries as well as Kerrisons and curettes. Foraminotomy was performed with a bur bilaterally and cartilaginous endplates were removed. A 5-0 curette was used to pull the posterior longitudinal ligament off of the spinal cord. Foraminotomy was done until a 5-0 curved curette could be passed out either side. At this point, the trials were used and a 7 mm cage was appropriate. This was then packed with stem cell bone graft and inserted in a retrograde fashion. A stent under lateral guidance was found to be appropriate. At this point, a Caspar post was removed from C3 and placed into C5, where this was distracted, and discectomy was carried out in the above fashion. Spinal cord was decompressed across the midline as the posterior longitudinal ligament was removed. Foraminotomy was performed with a high-speed bur, and cartilaginous endplates were removed. A foraminotomy was performed and the curette could be passed out bilaterally. At this point, trial was used and 7mm cage again was selected. This was filled with Trinity stem cell, impacted in a retrograde fashion into the appropriate position. At this point, appropriate length Zimmer Select plate was chosen and placed into position. AP and lateral showed an appropriate position, and screws were placed into C3, C4, C5 bilaterally. The locking mechanism was turned to prevent screw back out. Final images showed appropriate hardware with interbody grafts at C3-4 and C4-5. A drain was left anterior to the spine, and the platysma was closed in a running fashion. Sterile bulky compressive dressing was applied with a soft collar. The patient was awakened from anesthesia and sent to the recovery room in stable condition.

Codes Assigned
Listed in the table below is a comparison of the ICD-9-CM and ICD-10-CM diagnosis code for this procedure.

Note also that each digit of the ICD-10 diagnosis code is a specific identifier: M = Chapter 13-diseases of the musculoskeletal system and connective tissue; 45-49 = spondylopathies; 47 = spondylosis; 12 = with myelopathy, cervical region.

Now review the second table below, which lists the ICD-9 procedure codes against the ICD-10 procedure codes, and you will see that their descriptors differ.

In the ICD-10 index, coders start with the term Arthrodesis, which leads them to the anatomical region under the medical and surgical section, upper joints, fusion. All upper joints of the body are grouped in this column. Using the op report, work through each of the remaining four characters to assign the appropriate ICD-10-PCS code for the procedure(s) performed.

Like the ICD-10 diagnosis codes, each digit in the ICD-10-PCS column identifies a specific feature: 0 = medical and surgical; R = anatomical region, upper Joints; G = fusion; 2 = cervical vertebral joints, 2 or more; 0 = open; 4 = internal fixation device; and 0 = anterior.

Follow the same logic for assigning a code for the excision of the intervertebral disc.  In the index, access the term Discectomy, which will lead you to Excision, Upper Joints in the medical and surgical section.  Following the same steps as above, assign the following characters:  0 = medical and surgical; R = upper joints; B = excision; 3 = cervical vertebral disc; 0 = open; Z = no device; Z = no qualifier.

The following are the links to access the latest version of ICD-10-CM and ICD-10-PCS.

http://www.cdc.gov/nchs/icd/icd10.htm and http://www.cms.hhs.gov/ICD10/01m_2009_ICD10PCS.asp#TopOfPage

Susan Howe is a senior health care consultant at Medical Learning Inc. (MedLearn), St. Paul, MN.