MS DRG - SURGICAL : Spinal Fusion &

Related Procedure PCS coding

Nandesh.A.K , CIC
 DISCLAIMER

This presentation is intended for Educational purpose only.

The information shared here has been reviewed completely

for accuracy, the instructor does not accept any responsibility
or liability with regards to errors or misinterpretation and it
should not be considered as legal advice.

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Learning Objectives

Surgical MS-DRG – Introduction

Basic Anatomy

PCS Code structure

 Coding Guidelines

New Technology Coding

Additional Procedures

Coding Clinics

Coding scenarios

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MS DRG – SURGICAL
Major Diagnostic Categories (MDC)
Classification of principal diagnoses into 25 mutually exclusive diagnosis areas.

MS-DRG
Classification system to calculate pricing for inpatient hospital claims

MDC
 Medical MS DRG
 Surgical MS DRG

MS DRG(IPPS)
Main Factors that can alter DRG.
 Principle Diagnosis
 Secondary Diagnosis
 Procedure
 Discharge Disposition

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MS DRG - SURGICAL

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MS DRG - SURGICAL
MDC Description MS-DRG

1 Diseases and Disorders of the Nervous System 020 - 103

2 Diseases and Disorders of the Eye 113 - 125

3 Diseases and Disorders of the Ear, Nose, Mouth And Throat 129 - 159

4 Diseases and Disorders of the Respiratory System 163 - 208

5 Diseases and Disorders of the Circulatory System 215 - 316

6 Diseases and Disorders of the Digestive System 326 - 395

7 Diseases and Disorders of the Hepatobiliary System And Pancreas 405 - 446

8 Diseases and Disorders of the Musculoskeletal System And Connective Tissue 453 - 566

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 MS DRG - SURGICAL
MDC 8: Diseases and Disorders of the Musculoskeletal System And Connective Tissue (453-566)

DRG

MDC

DRG
TYPE

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MS DRG - SURGICAL
MDC 8 : Diseases and Disorders of the Musculoskeletal System And Connective Tissue (453 – 566)
MDC MSDRG TYPE Description

8 453 SURG COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC

8 454 SURG COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC

8 455 SURG COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC

SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W/O
8 458 SURG
CC/MCC
8 459 SURG SPINAL FUSION EXCEPT CERVICAL W MCC

8 460 SURG SPINAL FUSION EXCEPT CERVICAL W/O MCC

8 471 SURG CERVICAL SPINAL FUSION W MCC

8 472 SURG CERVICAL SPINAL FUSION W CC
8 473 SURG CERVICAL SPINAL FUSION W/O CC/MCC

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Basic Anatomy

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Basic Anatomy
Anterior Column Middle Column Posterior Column
Anterior Longitudinal Ligament Posterior Longitudinal Ligament Supraspinous Ligament

Anterior Annulus Posterior Annulus Interspinous Ligament

Transverse Process
Spinous Process
Anterior Portion Vertebral Body Posterior Portion Vertebral Body
Pedicles
Lamina
Facets

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Spinal Condition

 DDD/Arthritis of the Spine (Spondylosis)

 Degenerative Spondylolisthesis of the Lumbar Spine

 Fractures

 Osteopenia

 Osteoporosis

 Spinal stenosis (where there is an associated deformity)

 Lumbar Lumbago: Mild to Severe Low Back Pain

 Lumbar Radiculopathy: Low Back and Leg Pain. etc

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 PCS Code

 Fusion Definition: Joining together portions of an articular body part rendering the articular body part immobile

 Explanation: The body part is joined together by fixation device, bone graft, or other means

 Examples: Spinal fusion, Ankle arthrodesis

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PCS Code

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Dissection of Spinal Fusion Code

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PCS Code :Structure

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PCS Code :Structure

1 Section: Medical& Surgical

2 Body System: Upper/Lower Joints

3 Root Operation: Fusion

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PCS Code :Structure
4 Body Part

Factor determining number of Fusion codes

 Level (cervical, thoracic, lumbar and/or sacral) &
 Number of joints fused.

Example,
 L2-L5 Anterior fusion = one fusion code
 L2-S1 Anterior fusion = two fusion codes (one code with body part & other body part of 3)

B3.10a. The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is
classified by the level of the spine (e.g. thoracic). There are distinct body part values for a single vertebral joint
and for multiple vertebral joints at each spinal level

B3.10b. If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a
different device and/or qualifier.

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PCS Code :Structure

5 Approach Open

Percutaneous

Percutaneous Endoscopic

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 PCS Code :Structure
6 Devices

 Interbody fusion devices: BAK cages, PEEK cages

 Autologous Tissue Substitute

Bone grafts may be harvested locally using the same incision, or
from another part requiring a separate incision.

 Harvesting of the bone requires separate code when

performed through a separate incision.

 Nonautologous Tissue Substitute:

Harvested by a tissue bank from a cadaver

 Synthetic Substitute: Demineralized bone matrix, bone morphogenetic proteins (BMP)

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PCS Code :Structure
6 Devices

 B3.10c.Combinations of devices and materials

 Interbody fusion device = alone or containing bone graft

 Mixture of autologous & nonautologous bone graft (with or without biological or

synthetic extenders or binders) Coded with device value
Autologous Tissue Substitute

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PCS Code :Structure
6 Devices APPENDIX G: Device definition

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PCS Code :Structure

7 Qualifier

Anterior Approach, Anterior Column Posterior Approach, Posterior Column Posterior Approach, Anterior Column
(0) (1) (J)

Supine (face up) positioning Prone (back up) positioning Prone (back up) positioning

Incision front or side of the body Incision back side of the body Incision back side of the body

Structures on the posterior spine are

Vertebral body is fused Vertebral body is fused
fused

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PCS Code :Structure
7 Qualifier

Procedure Approach Qualifier

Incision in front of the spine through a mini laparotomy or laparoscopy
Anterior lumbar Ant Approach,
Less Risk for spinal nerves
(ALIF) Ant Column

Extreme/Oblique lateral Incision in side or Transpsoas Ant Approach,

(XLIF) (OLIF)(LLIF) Minimally invasive,flourscopy guided Ant Column

Direct lateral Ant Approach,

Incision made in the patient’s side
(DLIF) Ant Column

Posterior lumbar Incision through a midline in the back, 2 Devices may be used on sides Post Approach,
(PLIF) Ant/Post Column

Transforaminal lumbar Incision through a midline in the back, facet joint removed, better access disc Post Approach,
(TLIF) space.one device at centre Ant/Post Column

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PCS Code :Structure
7 Qualifier

Axial Lumbar Interbody Fusion (AxiaLIF)

 Common for L5-S1

 Minimal Invasive Transacral Incision next to coccyx with

Dilator Tube & Drill.
 Centre of Disc Removed, Thread Rods Inserted

NOTE:
 Anterior Approach & Column: ALIF, DLIF, LLIF, XLIF, Retroperitoneal
 Posterior Approach & Column: Posterolateral,Transpedicular,Transverse Process
 Posterior Approach & Anterior Column: AxiaLIF, PLIF, TLIF
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PCS Code :Structure
7 Qualifier

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PCS Code – New Technology

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CODING TIPS

 PLIF or TLIF techniques: Commonly used for both ANTERIOR & POSTERIOR Column Fusion
 Anterior Column Fusion > Interbody fusion device inserted
 Anterior Column Fusion > Anterior /Posterior approach
 Posterior Column fusion > Always done through Posterior Approach
 Combined anterior/posterior fusions may only have one incision
 Same Level different Column fusion require 2 codes
 Consider different body part for meeting joints of different levels ( thoracolumbar,Lumboscral etc.)
 Consider number of Level/Joints fused
 Do not miss Additional procedures
 Refusion
 Complications > Nerve Injury, Dural tear

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Additional Procedure
WHAT TO CODE ADDITIONAL ?

 Discectomies – Complete or Partial

 Decompression Release – Nerve or Spinal Cord
 Harvesting from separate site - bone or bone marrow
 Nerve Monitoring
 BMP if needed
 Disc Replacement
 Corpectomy

DO NOT CODE !
 Fixation devices/ Stabilization/Instrumentation devices (Rods, Plates etc.)
 Laminectomy as approach

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 Coding Clinics

Ant/Post
Column
Combined

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Decompression

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Disc Replacement

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 Corpectomy

 Corpectomy or vertebrectomy involves removing all or part of the

vertebral body, usually as a way to decompress the spinal cord and
nerves.

 Often performed in association with discectomy

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Discectomy & Fixation

Discectomy Fixation

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Coding Clinics : 1

Spinal Fusion with NuVasive® VersaTie® - Second Quarter 2020, Page 27

Question: A patient with multiple spinal conditions, including previous fusion, severe kyphoscoliosis, and severe
spinal and foraminal stenosis, presents for corrective surgery. Prior fusion instrumentation was removed, new
instrumentation was placed, and a new fusion was performed in the lumbar spine.

In addition to the multiple spinal procedures performed, a NuVasive® VersaTie® polyethylene tether was
woven through the interspinous ligaments via drill holes that were placed at the base of T8. The tether was
returned in a weave fashion and after full tension was achieved, the tie was locked into place to the VersaTie®
connectors that were placed at T11-T12. What is the appropriate root operation for placement of tether from T8-
T12?

Rationale:
Do not assign an additional code for the placement of the VersaTie® tether. Fixation instrumentation is
integral to the fusion procedure and no additional code is assigned.

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 Coding Clinics :2
Spinal Fusion without Use of Bone Graft - First Quarter 2020, Page 33

Question: A patient with progressive idiopathic thoracolumbar scoliosis, spondylosis with foraminal stenosis and
rib cage deformity was admitted for spinal fusion surgery. Through a right thoracotomy approach, a right anterior
spinal fusion was performed with placement of screws into the vertebral body and seating of a rod cord at T5-T11.
Significant correction of the scoliosis curve was obtained across the thoracic levels. The patient was repositioned for
exposure of the left side to complete left anterior spinal fusion at T11-L4. Screws were placed into the vertebral body
and a rod cord was secured across the levels with significant correction of the scoliosis and derotation of the
lumbar segments. What are the code assignments for this procedure?

Rationale:
In ICD-10-PCS, this procedure is not classified as a fusion, but rather as an anterior vertebral tethering
procedure. Reposition is the appropriate root operation.

 0PS404Z Reposition thoracic vertebra with internal fixation device, open approach; and

 0QS004Z Reposition lumbar vertebra with internal fixation device, open approach

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 Coding Clinics :3
Cervical Spinal Fusion Decompression & Placement of Interfacet Stabilization Device II Quarter 2019, Pg 19

Question: Patient with cervical spinal stenosis, myelopathy and radiculopathy, presents for surgical treatment
consisting of percutaneous posterior placement of DTRAX interfacet stabilization device with bone graft (C3
through C6). procedures performed included posterior laminectomy for cord decompression and partial
facetectomy. Harvesting of bone graft from the left iliac crest was accomplished via an open approach. Would
the placement of the DTRAX interfacet stabilization device be coded “Insertion” or “Fusion?”

Rationale:
 0RG2371 Fusion of two or more cervical vertebral joints with autologous tissue substitute, posterior approach,
posterior column, percutaneous approach, for the cervical spinal fusion

 00NW3ZZ Release cervical spinal cord, percutaneous approach, for the cervical decompression
 0QB30ZZ Excision of left pelvic bone, open approach, for the harvesting of the iliac crest bone graft

The DTRAX Spinal System is a set of instruments intended and indicated for access and preparation of a spinal
joint to aid in fusion.Should code the procedure based on what was done, rather than the device used. In this case,
a posterior fusion between the facet (interfacet) was done, not an interbody fusion.

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 Coding Clinics :4
Spinal Fusion Same Level as Decompressive Laminectomy - First Quarter 2019, Page 30

Question:

The patient is a 72-year-old woman diagnosed with lumbar stenosis and spondylolisthesis with scoliosis. She
underwent decompressive laminectomy at L2, L3, and L4. This was followed by lumbar spinal fusion with
interbody cages at L3-L4 and L4-L5. Is decompressive laminectomy coded separately when it is performed at the
same level as a spinal fusion?

Rationale:
In this case, the decompressive laminectomy was performed to treat a separately documented diagnosis of
lumbar spinal stenosis. Since there is a distinct objective, it is appropriate to code decompressive laminectomy even
though it was performed at the same level as the lumbar spinal fusion. The root operation Release is coded
separately when decompression is documented, and there is a distinct surgical objective, not just incidental removal
of the lamina to reach the site of the procedure. If the laminectomy is done as an operative approach to prepare for
the spinal fusion, it is not coded separately.

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 Coding Clinics :5
Decompression of Spinal Cord and Placement of Instrumentation Second Quarter 2017, Page 23
.

Question: 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.

Rationale: In this case, a spinal fusion was not carried out. There was no documentation of bone graft or a
bone graft substitute being utilized; only spinal cord decompression and insertion of rods and screws
(instrumentation) were accomplished. Instrumentation alone does not constitute a spinal fusion. Further, the insertion
of rods and screws is not the same as the placement of a pedicle based stabilization device. The device value “Spinal
stabilization device, pedicle based” is not used, because that device value is only used for specific stabilization
systems.

Release” is coded separately when decompression is documented, and there is a distinct surgical objective

0PH304Z Insertion of internal fixation device into cervical vertebra, open approach

00NW0ZZ Release cervical spinal cord, open approach

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 Coding Clinics :6
. Intraoperative Monitoring Using Sentio MMG® FIRST QUARTER 2015, Page 26

Question: A patient was admitted for partial vertebrectomy with anterior lumbar interbody fusion
and placement of anterior prosthetic device. The Sentio MMG® surgical access tool was used
during the procedure to ensure protection of the nerve roots. What is the code assignment for the
intraoperative use of Sentio MMG®?

Rationale: Facilities may choose to report or not report this procedure. The Sentio MMG® is
similar to an EMG with the sensors being placed on the skin. There is variability where the probe
is placed and the measuring device is external. In this case, monitoring is the procedure
performed (monitoring is simply a series of measurements repeated over time) and the external
approach should be used, since sensors are placed on the skin. If the facility has chosen to report
this procedure, assign the following ICD-10-PCS code:

4A11X4G Monitoring of peripheral nervous electrical activity, intraoperative, external approach

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 Coding Clinics :7
Placement of Bone Morphogenetic Protein & Spinal Fusion Surgery First Quarter 2018, Page 8
.

Reporting a code for the placement of BMP is optional and facilities may code it, if desired. When an open
approach is used, assign the following ICD-10-PCS code

3E0U0GB Introduction of recombinant bone morphogenetic protein into joints, open approach

Composite Grafting (Synthetic versus Nonautologous Tissue Substitute) Second Quarter 2014, Page 6

If biologic material is mixed with synthetic material, assign to nonautologous tissue substitute. Tissue-engineered
products may be cellular or acellular, and derived from biological tissue, synthetic material, or a mixture of biologic
and synthetic material. Since composite material always has a biologic component, it is always coded as a
nonautologous tissue substitute.

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CASE SCENARIO : Posterior Lumbar & Direct Lateral
Interbody Fusion

Rationale :

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CASE SCENARIO : Fusion, Lumbar with Decompression and
Discectomy

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SCENARIO

RATIONALE :

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OPERATIVE REPORT : 360 Fusion/Combined Fusion

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 OPERATIVE REPORT

Anterior Column
Fusion at L5-S1

Posterior Column
Posterolateral L4-S1

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OPERATIVE REPORT

RATIONALE :

 0SG30AJ
Fusion of Lumbosacral Joint with Interbody Fusion Device, Posterior Approach, Anterior Column, Open
Approach

 0SG3071
Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Posterior Approach, Posterior Column,
Open Approach

 0SG0071
Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior Approach, Posterior
Column, Open Approach

 0SB40ZZ
Excision of Lumbosacral Disc, Open Approach

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QUESTIONS

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 Reference & Resources
 https://www.spine-health.com/treatment/spinal-fusion/lumbar-spine-fusion-degenerative-disc-
disease
 https://www.velocityhc.com/wp-content/uploads/2019/09/CDIBC_03_IPPSandMSDRG_SG.pdf
 https://www.cms.gov/icd10m/version37-fullcode-cms/fullcode_cms/P0375.html
 https://www.cms.gov/icd10m/version37-fullcode-cms/fullcode_cms/P0001.html
 https://library.ahima.org/doc?oid=300281
 https://www.pinterest.com/pin/260645897169826662/
 https://www.infinitee.com/celebrating-30-years-of-infinitee-and-endless-possibilities
 https://tenor.com/search/coding-gifs

Books
 ICD PCS Coding
 Applying ICD PCS guidelines 2020

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