Q&A: Reporting spinal fusions in ICD-10-PCS

Q: For fiscal year (FY) 2019, how would a spinal fusion without any bone grafting material be reported in ICD-10-PCS?

A: This is tricky, because according to the FY 2019 IPPS final rule, this is not technically considered a fusion now. CMS deleted the “no device” option in these ICD-10-PCS tables, which means fusions now require a device in order to be reported.

A fusion would need an instrumentation with a bone-graft material or a bone graft alone to facilitate the fusion of the vertebral bones for a spinal fusion. CMS wrote a lot about spinal fusions in the final rule, but keep in mind this applies to all the joints in ICD-10-PCS tables 0RG (joints for the upper body) and 0SG (joints for the lower body).

Since CMS deleted the “no device” option in those tables for FY 2019, this solidifies the fact that you will need some sort of device to complete your code. Also, CMS specifically said the device needs to be a bone-grafting material because that is what will fuse the bones together.

If you are reporting some sort of stabilization procedure using a stabilization device in that joint area and the physician didn’t fuse them together with a grafting material, perhaps an Insertion of a device would be the more applicable root operation.

Always keep your eye out for upcoming Coding Clinics, as I’m sure coders will be submitting a lot of questions about these new guidelines in the next couple of quarters.

Editor’s note: Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, regulatory specialist for HCPro in Middleton, Massachusetts, answered this question.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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