Of all the challenges associated with the transition to ICD-10-PCS, coding spinal fusion procedures is by far the most difficult to tackle, in this author’s opinion. Even after training, many coders still struggle with the complexities of coding these procedures. This article focuses on the importance of thoroughly reviewing operative reports and offers valuable insights and practical strategies for ensuring accuracy, improving efficiency, and avoiding costly errors. 

Dispelling the Confusion – Interpreting Operative Reports

An understanding of spinal anatomy, physiology, medical terminology, and surgical descriptions included in operative reports is required to achieve correct coding assignment for spinal fusions. Fortunately, there are certain clues and helpful guidelines we’ve discovered to help coders know what to look for and how to interpret the content.

When we train coders to assign PCS codes to spinal fusions, we begin with the seventh character: the qualifier. The qualifier denotes whether the surgeon approached the patient from the front or back, and whether the front or back column of the spine was fused. There are three qualifier options: 

  • Anterior approach, anterior column
  • Posterior approach, posterior column
  • Posterior approach, anterior column 

As these suggest, there are two ways to get to the anterior column: dissection from the front through visceral organs, or a “sneak around” from the back.


The first thing we look for in the operative report is the patient’s positioning for surgery. If the patient is supine (face-up), the surgeon is likely using an anterior approach. If the patient is prone (face-down), the surgeon is likely using a posterior approach. Note that the approach doesn’t necessarily indicate the column the surgeon is working on.

An anterior approach involves quite a lot of dissection through visceral organs. Often there’s a separate operative report from a different surgeon who only performs the approach. This is confusing because there is no code for the anterior approach alone. But having a separate report is a huge clue that an anterior approach may have been performed. Once the approach is completed, the neurosurgeon takes over to perform the spinal fusion procedure. Even though two surgeons are involved, the approach performed by the first surgeon is coded as an element in the spinal fusion procedure performed by the neurosurgeon.


Once the approach is determined, the coder must figure out the part of the spine being fused. Spinal fusions involve a variety of devices. For example, the procedure may require placement of an interbody fusion device, which always means fusing the anterior column. 

Other devices include autologous tissue substitute, internal fixation, non-autologous tissue substitute, and external fixation device. Use of a femoral ring allograft, a piece of cadaver bone from the femur, can be confusing as it pertains to selecting the device – because it would seem to be a tissue substitute, but it is actually an interbody fusion device. Again, this indicates focus on the anterior column. ICD-10-PCS Guideline B3.10c explains how to apply the device value for fusion procedures when a combination of devices is required.

360-Degree Fusion

One of the most confusing procedures is a “360-degree” fusion involving both the anterior and posterior. Coders sometimes code only the anterior fusion and miss the posterior fusion. The operative report may mention “posterior fusion; posterolateral gutter packed with bone graft,” which is a procedure performed along with the use of rods, plates, and screws that stabilize the spine until the fusion takes effect. Instrumentation is not coded separately.

We train coders to read both the body and the header of the operative report. If the header mentions posterior fusion, then dig through the report to find it and make sure it’s coded. Coders often say, “I understand an anterior fusion was done, but where in the report does it say there was posterior fusion?” Look for the statement: “the posterolateral gutter was packed with bone graft.” In other words, bone graft material was placed on the posterior column in order to fuse the area. Locating this documentation is like finding a needle in a haystack, and it’s usually in the description of the pedicle screw placement. A coder who remembers the rule, that fixation is not coded, might skip the paragraph indicating that the posterior fusion was done. 

Mistakes often happen when coders scan or stop reading the content. Attention to detail is critical. In one training session, a coder came up with a practical mantra: keep reading – all of the words. 

Impact of Mistakes and Missed Information 

Data accuracy and reimbursement depend on proper coding, documentation, and reporting. For example, from a financial perspective, an anterior approach yields a higher-paying DRG. And there’s a significant payment difference between coding both anterior and posterior fusion and coding just one or the other. Doing both almost doubles the relative weight. Failure to code the posterior fusion in a 360-degree procedure results in a significant amount of missed reimbursement. 

In our experience conducting ICD-10 training for more than four years, people are still challenged by coding spinal fusions. To achieve accurate and complete coding, coders must know the language of operative reports and understand exactly how procedures are performed. Here are four tips to help coders at all levels, new and experienced, visualize and understand the procedure:

  • Google “spinal fusion” to find images and videos that clearly depict aspects of the procedure. Visit www.innerbody.com, a free virtual human anatomy website that shows detailed spinal images (2-D interactive and 3-D rotate-and-zoom).
  • For those who prefer books, consider the Anatomical Chart Company series available at www.amazon.com. These publications include detailed anatomical charts and images like those you see in physicians’ offices.
  • Invite a surgeon who performs spinal fusions to attend a “lunch-and-learn” event. Physicians typically like to talk about what they do, using visual aids and hands-on models to describe the procedure.
  • Designate one or two specialty coders to focus on spinal fusions, and also help with pre-billing review. This is an effective way to improve efficiency, expertise, and teamwork. 

Addressing Issues through Education and Training

Given the complexity of proper coding of spinal fusions, our staff has tried a variety of approaches to address specific issues. Visuals and other hands-on aids help tremendously with such a complex topic. Here are several examples: 

  • Create images that make it easier for coders to visualize spinal anatomy. Our current library includes individual images of anterior and posterior fusion.
  • As new devices are introduced, provide more device images and clues to help coders.
  • Encourage face-to-face, hands-on training for coders. They want to see and handle a model of the spine – have them take it apart and understand how each individual piece of the anatomy fits into the whole.

Even with the best training, coders are not consistently coding a high volume of spinal fusions to promote retention of information. Designating a specialty coder to serve as the expert works well; it’s best to have a guru on staff as the go-to person to help with questions. The more of these cases you code, the more proficient you become. 

Kudos to Coders – Preparing for the Future 

Overall, coders have done an extraordinary job of preparing for ICD-10. Even though PCS coding requires an unprecedented level of detailed understanding when reading operative reports, we have been impressed in audits by how well coders are performing. The learning curve was huge.

Again, coding spinal fusions is absolutely the hardest procedure to code in PCS. And while coders are doing well, there’s always room for improvement, and we’re ready for the challenge. Kudos to coders! They deserve high praise for their commitment and perseverance. 

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