Good afternoon, everyone, and welcome back to our spinal cord injury series. Today's webinar is going to address spinal cord injury from the registry perspective and looking at coding. It's titled Spinal Cord Injuries, Coding Spinal Cord Injuries for Registrars. And it's my privilege to introduce today's speaker, Robin Schrader. Robin's background includes over 34 years in the healthcare industry with 16 of those in the registry. And over these 16 years, Robin's worked as a registrar, PI coordinator, and registry manager for several level one adult, level one pediatric, and ABA verified burn centers. Currently, she is the Trauma Registry Operations Manager for Virginia Commonwealth University Medical Center in Richmond, Virginia. She also works for the Pennsylvania Trauma Systems Foundation as a contract registry auditor and educator. She is the former chair of the American Trauma Society CSTR Prep Committee, and she is the educator for the Association of Virginia State Trauma Registrars. She also has a voice in the trauma registry in many organizations. She's a member of the TCAA Registry Education Committee for the American Trauma Society. Robin is on their CSTR Leadership Advisory Council, part of their CSTR Mentor Program on the TRDC Committee. And last but not least, she is an ICD-10 coding instructor. Clearly an expert, she's spoken at many conferences, has posted several webinars for the American Trauma Society, TCAA, TRAM, and has done several AMN Revenue Cycle Education podcasts on topics such as performance improvement and hospital events complications. In her spare time, I don't know where she finds spare time, but in her spare time, Robin enjoys spending time with her husband of 31 years, and their son, and their three dogs. So I am going to turn it over to Robin, and welcome to the series. Hi everyone, thank you, Kim. I am happy to be here today and talk about spinal cord injuries, and coding of spinal cord and vertebral column injuries. So let's get started. The TCAA Educational Statement is just from TCAA, their disclosures and their accreditation statement. I have no disclosures. The objectives for today is to recall the anatomy of the spinal cord and the spine, describe coding principles for spinal cord injuries, describe coding principles for vertebral injuries, and describe the coding principles for coding procedures related to spinal cord and vertebral column injuries. So starting off with a little bit of anatomy, the spinal cord in general, you have your C-spine, you have your seven cervical vertebrae, and there's actually eight nerves attached to the cervical spine, and those nerves supply your head, your neck, your shoulders, your arms, your hands, also into your diaphragm, your thoracic, you have your 12 thoracic vertebrae, and those nerves, as you can see, go to your hands, upper abdomen, your muscles in the back and chest, and then your lumbar spine, five lumbar vertebrae, and those nerves go to your back, your hips, your quadriceps and hamstrings, your knees and your feet. And so you have pairs of nerves out one side for the left, one side to the right, and then your sacrum. And again, the sacrum, you have those five sacral vertebrae and your nerves to your bowel and bladder, buttocks, legs, feet, and also control sexual function. Looking at the spinal cord, you have the central canal, and that's the opening between the vertebrae where that spinal cord passes through, and you see that here in yellow is your spinal cord, and then you see your vertebrae there that surrounds and protects it. And there you see your nerve roots and that neuroforamen, which is where those nerves pass through and go out to your body. So the spinal cord's covered by that protective membrane, the dura mater, and obviously your brain is also covered by that. And inside that sac of the spinal cord is surrounded by your cerebrospinal fluid. So same as your brain protecting and padding it from injury. And then that neuroforamen there, where those nerve roots travel through to reach the rest of your body. So there's two neuroforamen between each pair of vertebrae, and there's one on each side, left and right. So there are several types of spinal cord injuries, and here is just a little diagram showing a spinal cord injury. So an acute spinal cord injury, or SCI, a traumatic injury that bruises, partially tears, or completely tears the spinal cord. So that can be due to a vertebral fracture, a dislocation, there may not even be a fracture, it may just very well be a spinal cord injury. And of course, spinal cord injuries can lead to permanent disability and or death. So the main mechanisms that we find spinal cord injuries, falls, motor vehicle crashes, pedestrians struck, sports injuries, and violence. So obviously gunshot wounds or stabbings. Symptoms of the acute spinal cord injury. So location of injury will determine what part of the body is affected and how severe the symptoms are. As I showed you in that diagram with the nerves, obviously depends on what level of your body, if it's a C-spine, the thoracic spine, the lumbar spine, is going to depend what part of your body and even what level on the spine of each particular. So a C2 fracture or a C2 spinal cord injury is going to be different than a C7 spinal cord injury, with what's affected. The higher the level, the more severe the symptoms. So C1 through C5 affect the respiratory muscles and the ability to breathe. So like I said, at C2 is the nerves that go to your diaphragm. So obviously you can have respiratory muscles and your ability to breathe, obviously taken away by this type of an injury and leaves you on a ventilator permanently. Lumbar injury may affect nerve and muscle control to the bladder, bowel, legs and sexual function. And remember, when you have patients who come in that they may very well have a spinal cord injury, you'll see that the physicians, if you're reading their notes, they're looking at rectal tone to know whether they actually have tone there in their bowel, right? Looking for certain signs that we have an injury. Quadriplegia is a loss of function in the arms and legs and paraplegia is a loss of function in the legs and the lower body. And we use this American Spinal Injury Association scale, the ASIA scale, right? I'm sure most of you have had this referred to, especially if you have a patient with an SCI and you have rehab or physiatry who comes and sees them. And most times they're using this ASIA scale. So ASIA, ASIA-A is what you'll hear, ASIA-A, ASIA-B, ASIA-C, ASIA-D, ASIA-E. So looking at the scale, you see what the features are. So in A, there's no motor or sensory function below the lesion level. So that means if it's at C2, there's nothing below C2, right? And that's a complete spinal cord injury, all right? And then ASIA-B, they're sensory, so they have some sensation, but no motor function below that lesion level. And this is considered an incomplete injury. ASIA-C, muscle grade less than three out of five below the lesion level. And I think everyone knows that you'll see all of those gratings that they go through, your arms and legs and looking at that grade. So three out of five below, and that's incomplete. And then in ASIA-D is muscle grade three or greater below the lesion level, of course is incomplete. And E is normal function, so there's no injury. Symptoms of that acute spinal cord injury, muscle weakness, loss of voluntary muscle movement in the chest, arms, and legs, breathing problems, loss of feeling in the chest, arms, and legs, and loss of bowel and bladder function. Again, there's that rectal tone that they'll look for when we have a suspected spinal cord injury in the trauma bay. So you have the complete versus incomplete and in general, your complete injury, you have no movement or feeling below the level of injury. So the patient can't move arms and legs or just legs. And an incomplete, there's still some degree of feeling or movement below the level of injury. So they may have that sensation where they can feel you touching, but maybe they can't move their legs or their arms. So looking at our incomplete injury, so looking at our incomplete spinal cord injuries, so we have anterior cord syndrome. And again, what I have added here are your ICD-10 codes where anterior cord syndromes would be coded. So I have listed for each part of the spine. So anterior cord syndrome is an injury to the front anterior of the spinal cord. So the anterior is the front two thirds of that cord. Motor paralysis below the level of lesion is what you have a loss of. And then you have the posterior cord syndrome. So that's an injury to the back of the spine. And then below the level of the lesion, your motor function is preserved, but you lose your sensory function. So pressure, stretch, sense of your position. So you maybe don't know where your legs are at or how they're positioned and poor coordination. So the central cord syndrome is the most common type of spinal cord injury. It's an injury to the center of the spinal cord. The motor deficits are worse in the upper extremities than the lower extremities. You may have possible bladder dysfunction there, so retention. So they just, they can't empty their bladder or don't feel the sensation. And then recovery of some movement in the legs is possible, but it's very rare in the arms. So that's for central cord syndrome. And we do see central cord syndrome, I think most commonly in our trauma-related cases. Brown-Saquard syndrome. So again, the injury is on one side of the spinal cord, right or left. The side where the injury is located is affected the most. You can have weakness or paralysis, loss of positioning sense on the side of the injury and loss of pain and temperature sensation on the opposite side of the body. So where you have that weakness or paralysis on the side that you have the injury, on the opposite side, you may have lost pain and temperature sensation. And so working for a burn center, sometimes we get patients who are paraplegic or have some kind of a spinal cord injury and they end up getting burned because they can't feel, especially the temperature of, it might be running bath water and they put their feet in and they end up getting burned. They can't feel it and they have burned. So again, losing that sensation on one side. Cauda equina syndrome. So cauda equina is damage to that bundle of nerve roots around the lumbar level of the cord. And the name becomes because it looks like a horse's tail. There's spinal compression there. It weakens the affected muscle and creates loss of sensation but movement may not be affected. So again, they can move but they don't have sensation in that area. And then throwing in a whiplash injury, which is a sprain of the ligaments of the cervical spine. There is the code for ICD-10. And when you go into AIS, you have a cervical strain code and that's where you would code your whiplash injury. Types of complete spinal cord injuries. So the cord is fully compressed or severed, results in complete bilateral paralysis below the injured site. Okay, so complete paralysis. Both sides of the body are affected equally. Sensory and motor function are completely lost below the point of injury. So again, depending on where that injury is, if it's the C-spine, the T-spine, the L-spine, is going to depend on where that sensory and motor function is lost. Quadriplegia or tetraplegia is a loss of all sensory and motor functions that affects all four limbs. So the lesions in the cervical spinal cord, and again, all four limbs are affected. So that C-spine really being the one that causes the most severe injuries. Paraplegia being a loss of all sensory and motor functions in their legs and generally the pelvis, but not the arms. So those are patients who you'll see, maybe the waist up, they have movement. It's the waist down that they have zero sensory or motor function. So that lesion is located in the thoracic or lumbar spine. And these people are usually more independent, right? Because they still can use their upper body. So again, quadriplegia would be a cervical spinal cord injury. Paraplegia would be thoracic or lumbar. Looking at some fractures. So several different kinds of fractures to go over. And I get a lot of questions about fractures. So a stable fracture usually involves the anterior column. And again, you look for the physician to term them as stable or unstable. Super important when you're coding. Compression fractures are usually stable. They do not cause spinal deformity or neurologic problems normally. Unstable. So an unstable fracture, they make it difficult for the spine to carry and distribute weight. So what is your spine there for? Well, obviously it helps to hold you upright and it carries all of that weight that it distributes throughout your body. So they have the chance to cause more damage. So if you have an unstable fracture and you're not kept immobile, they can cause more damage and they can cause spinal deformities. Usually they are a three column injury. Not always, but usually. Again, your flexion distraction injuries usually involve fractures in the middle and posterior columns where a fracture dislocation usually involves all three columns and make the spine very unstable. So when you look at your CT scans or what either your ortho spine or your neurosurgeon talk about, when you have a fracture dislocation, that is usually an unstable fracture. So types of spinal fractures. Continued, a burst fracture. And you see a burst fracture that shatters the vertebrae on all four sides. So there's shards of vertebrae penetrating surrounding tissues and possibly the spinal cord. You can have them stable or unstable. And usually a burst fracture, you could get that a fall from a height and you land on your feet and it will burst that vertebrae. It just shatters. And of course those shards are important because when they go into the spinal canal, that's where you experience then spinal cord injury as well. Your compression fracture. So that's like a collapse of the vertebrae. There can be a loss of height. Anterior part of the vertebrae is normally where you see that loss of height. It's extremely rare to be posterior, extremely rare. So I don't think I've ever, ever experienced a compression fracture where it was the posterior part of the vertebrae where you had that height loss. A wedge compression fracture. So the wedge compression is a part of, is a type of compression fracture. It's the most common type of compression fracture. And that's where a part of that vertebrae, usually the anterior, collapses under pressure. And it's just that it's a part of it. It's not the whole thing. A chance fracture. So a chance fracture is a horizontal fracture through the spinal process, the pedicles and the vertebral body. So that is a three column injury. And we're going to get into that in a few slides. But again, that chance fracture goes through the spinal process, the pedicles, the vertebral body, okay? A thoracolumbar junction may involve spinal ligaments. So if you have a chance fracture at that thoracolumbar junction, you may also have spinal ligaments involved. Again, always looking for, did they do an MRI? And what does it say about these ligaments in the spine? In that chance fracture, that vertebrae is pulled apart. So again, that's why you're looking at spinal ligaments. It actually pulls apart. And they are caused by that violent forward flexed injury like in a motor vehicle collision. And it is an unstable flexion distraction injury. So chance fracture, think about when you see a chance fracture that's not good. That's a pretty severe fracture. Types of cervical spine fracture. So there are several types of cervical spine fractures. Extension teardrop fracture, which usually causes traumatic spondylolisthesis. Forced extension of the neck resulting in a vulsion of the anterior inferior corner of the vertebral body. So there may be a ligamentous injury, it's unstable. And there's a high incidence of cord damage. So that's an extension teardrop. All right, and you see the little diagram there that shows you the flexion teardrop and then the extension teardrop. So the flexion teardrop, again, is the most severe fracture of the C-spine. So there you see that flexion teardrop and that interspinous ligament is torn in the diagram there on the top. Combination of extreme flexion and compressive forces. So a dive into a shallow pool and you hit your head and what happens to your neck, right? So if you ever know anybody that this has happened to, and I actually personally knew somebody many years ago who she was only 17 when she did a pretty good dive into a shallow pool and ended up completely quadriplegia, neck down, no movement, no sensation, nothing. Really, really was sad. So again, it's most commonly C5, C6 is where you will find this flexion teardrop fracture. And it's associated with anterior cervical cord syndrome and or quadriplegia. It's unstable with disruption of ligaments and bones. So you see there that you have with the flexion teardrop that interspinous ligament is torn. And with the extension teardrop, you have that disruption of the anterior longitudinal ligaments. So again, very unstable. The bottom picture is your hangman's fracture and your hangman's fracture is a hyperextension injury. And it's a fracture of the bilateral pars of C2. And you see that picture there. So both pars are fractured. And then your odontoid fracture or your DENS fracture. It's low energy falls in the elderly. It's the most common type of C-spine fracture in elderly patients. And in younger patients, it's a high energy traumatic injury. they account for about 20% of C-spine fractures. So they're pretty common, especially in the elderly. And if you're at a mostly geriatric center, I'm sure that you see plenty of dense fractures. Jefferson fracture. So your Jefferson fracture is a burst fracture of C1, the atlas. It's the only vertebrae, C1's the only vertebrae without a body. So there's no body on that fracture. And the next slide is going to actually show you some pictures of this. It's an axial load from the occiput downward. Fractures, one or both anterior or posterior arches. There are four types. Those four types are a type one is the anterior arch. A type two is the posterior arch. A type three is the anterior and posterior arch. So a double fracture. And then the type four is that lateral mass fracture. So it's dependent on the speed of the axial pressure. Low speed tends to cause the type four. Something high speed is type three or burst fractures of two to four parts. Okay. And here are your spinal columns. As we talked about a little bit earlier with fractures being in, you know, you can fracture something in each column or just one column, two columns, but your anterior is the front part of the vertebrae that faces the body. The middle is the key part of spinal stability. So the back half of the vertebral body and intervertebral disc, the posterior longitudinal ligament is located there. So that's in the middle column. If the middle column stays intact, you're more likely to have a stable fracture. Okay. And then your posterior or the back is the pedicles, lamina, facet joints, and the spinous process. Now looking at these Jefferson fractures. So here are your Jefferson fractures. I wanted to throw this in so that you actually would have something to reference. And for some reason, they're not in order in this fracture in this diagram, but you have your type one, your posterior arch fracture. So there you see your posterior arch type two, your anterior arch fracture, right? Type three up here is your burst or Jefferson fracture. And you see they're both your anterior and posterior. And then type four is that lateral mass fracture. Okay. So, and again, it's showing you the kind of rotation and load that happens to cause this kind of a fracture. Okay. At your C1. Fracture dislocations and dislocations of the spine. So the most common unstable vertebral injury involving all three vertebral columns, right? So cervical spine is a broken neck. And a broken neck, a motor vehicle collision, falls, sports, and obviously violence. A dislocation is due to a ligament injury. You may have core damage and usually they're associated with a flexion extension injury. At lanto-occipital dissociation, AOD. I've seen this actually several times. It's highly unstable injury. And this little picture here is an x-ray of a lanto-occipital dissociation. So what is it? It's an internal decapitation. So your head is not attached to your spine. You see that, right? You see the head there. It is not attached to the spine anymore. So it is a ligamentous injury. It has about a 50% mortality rate. I am going to tell you that most people wanted to think right away that this means the patient is dead. The patient, not necessarily. The mortality rate used to be a lot higher, but with technology and advancements in trauma care, it has been reduced to 50%. But again, think about it. It's an internal decapitation. They present with symptoms of compression to the brainstem or cervical cord. Neurological deficits, often quadriplegia. If a cord injury is present, you would code it to the cord injury. But if there's no cord injury present, you would code under that cervical spine dislocation. All right. So cord injury, if there is a cord injury associated with this dissociation, then you would code it to that cord injury. And again, if not, it just goes under that cervical spine dislocation. Thoracic spine fracture dislocations, they're unstable. You may have spinal cord or nerve damage. And usually, it requires some type of stabilization surgery for a thoracic spine fracture dislocation. Thoracic spine fracture dislocations, again, if it's unstable, spinal cord and nerve damage, and your stabilization required. So looking there, you have a thoracolumbar fracture dislocation, the slide on the right. And you can see there that not only is there a fracture, but look at the dislocation, right? The spine is way out of whack there. And then your lumbar spine, again, unstable, spinal cord or nerve damage, and surgical stabilization is also normal for that. So when you have those fracture dislocations, you're most often going to see that patient going to the OR for repair. All right. So looking at some diagnosis coding principles. Coding injuries to the spinal cord and vertebral column. So a fracture with a spinal cord injury are coded together as one injury in AIS. You have that, for example, C2 epidural hematoma with paraplegia and a C2 burst fracture. So looking at this coding, you have an ICD-10 of another displaced fracture of the second cervical vertebrae. And then you have a C2 epidural hematoma, which actually gets coded. So think about your spinal cord injuries in ICD-10 get coded, at least a hematoma as a concussion and edema. So there is S14 for the C-spine. Again, it would be S24 for thoracic and 34 for lumbar. And again, just remember that in AIS, you're coding this with one code. So you have a fracture and that hematoma. So you have that epidural hematoma with your fracture. And so that's going to be one code. All right. When a cord injury is continuous, you are only going to code to that highest level. So example, your epidural hemorrhage from C5 to T2. So you get an MRI back and the patient has an epidural hemorrhage from C5 to T2. You are going to code the cord contusion at the C5 level. Okay. That's the only level that you code, the highest level. That's always where you're going to go. When a cord injury is in more than one place and the injuries are separate, not continuous, you are going to code all injuries separately. So if you get an MRI back and it tells you that the patient has an epidural hematoma C3 with a fracture, and then an epidural hematoma at L4 with a fracture. Okay. It doesn't tell you that it's continuous. And if they did an MRI and you have a C-spine, a T-spine, and an L-spine separate, these would be coded separately. So AIS, those injuries would be coded separately to the two codes. So obviously your epidural hematoma in the C-spine with a fracture, and then your epidural hematoma in the L-spine with a fracture. And then you would actually have four codes in your ICD-10 for your hematoma in the spinal cord along with the fracture. Okay. They get coded a bit differently. And then multiple fractures of the same vertebrae. So that means you have all the different parts of the vertebrae, the spinous process, the transverse process, the facet, the lamina, the pedicle, the body, the odontoid for C2. So you code as one injury in AIS, which is that multiple fracture code. That does not include a major compression fracture. That would be separate. Okay. But I have gotten the question regarding, well, what if it's, you know, fractured in the same column? So in column three, you have two fractures. So you have the spinous process and the facet fractured, right? It's just, it's not a multiple because it's in the same column. No, it doesn't go by the column. It goes by the part of the vertebrae. So more than one part of that vertebrae is fractured. It is a multiple fracture. Your only exception is that major compression fracture. If it's a minor compression fracture, then it's included in that multiple. Okay. So again, T4 minor wedge compression fracture and a superior end plate fracture. So you would use that multiple code, but then in ICD-10, you would have that wedge compression fracture and then the superior end plate fracture. Okay. So two codes versus one multiple code in AIS, and there is not a multiple code to use in ICD-10. All vertebral fractures should be coded separately. So again, if you have a fracture of the spinous process of T1, T2, T3, T4, and T5, all get coded separately. So you would have your ICD-10 and AIS codes for T1, for T2, for T3, for T4, and for T5. Okay. They all get coded separately. Coding of spinal cord injuries at all levels. So a contusion of the cord, which in ICD-10 says concussion and edema. And then your AIS description is your contusion, compression, epidural, or subdural hemorrhage within the spinal cord. And then again, we know that you have a code to code them with your fracture dislocation, with no fracture dislocation, with a fracture only, with a dislocation only, and with paresthesias, but not further specified as to the fracture and or dislocation. All right. And we have that at all levels of the cord. And again, making sure that you are coding, again, appropriately in both your AIS and your ICD-10, since they differ. Your incomplete cord syndrome. So you have anterior, central, or lateral cord syndrome. And again, these also go with or without fracture dislocation all the way through, just like the other, like the one above. You have central cord syndrome at C-spine level, anterior cord syndrome at C-spine level, brown silk cord at C-spine level, and then other incomplete lesion at cervical spine level. And then I just have included in there the thoracic and lumbar spines, which are the same codes. It's just, instead of listing everything out, it gives you direction of where to look. And then your complete cord syndrome. So quadriplegia or paraplegia, with or without your fracture dislocation. Again, you're going to have all of those choices at each level of the spine. Vertebral disc injuries. So radiculopathy is a pinched nerve injury or damage to the nerve roots in the area where they leave the spine. Okay, you can have tingling or numbness in the fingers or hands, weakness in the arms, shoulders, or hand, decreased motor skills, loss of sensation, or pain associated with movement. So if anyone has ever had a herniated disc, or a herniated disc, a herniated disc, especially in that C-spine, you know that if it herniates out and it's being pinched, that nerve's being pinched, you probably have pain that radiates from your neck. It could be in your shoulder. It could go all the way down into your hands and fingers. But same kind of thing. Disc herniation, there's that bulge, slipped, or ruptured disc. That can occur in any part of the spine. It is common in the lumbar and cervical spine, most common in those two parts of the spine. Coding of disc herniation with AIS codes is either not further specified with radiculopathy, without radiculopathy, or rupture of that disc. And again, you would have to look at the MRI, most likely for any type of disc injury, they're going to do an MRI. And then again, there are your codes for the cervical, thoracic, and lumbar when it comes to ICD-10. And again, I would love to share the AIS codes with you as well, but AAAM tells us we're not allowed to do that. So AIS coding for ISS calculation. So the cervical spine injuries are assigned to the head and neck for your ISS. Thoracic spine injuries are coded to the thorax, chest body region. And lumbar are assigned to the abdomen and pelvic contents for your ISS body region. So remember that when you look in your book, you have that spine tab, right? But that's not a body region. So they have to be assigned to certain body regions for your ISS calculation. There they are. All right. Looking at a few procedures. Spinal decompression. So your laminectomy is a removal of part of the vertebral bone, the lamina, and it creates a space in the spinal canal to decompress the spinal cord. So there is your part of your code where you would start for a spinal decompression. And that spinal decompression is a release or freeing a body part from an abnormal physical constraint by cutting or by the use of force. So here you're going to release that spinal cord and you would have to add in your body part and your approach. Okay. Excision is the removal of that lamina from the vertebral bone. And there are your codes depending upon where you are doing it. And of course, the body parts. So your upper versus lower and then whatever the approach happens to be. If it's open, if it's percutaneous, endoscopic, percutaneous, whatever it happens to be. And remember, when you are looking at those open versus percutaneous, remember, open is exposing a body part to literally look in and see that body part that we are doing the procedure on. So doing an incision in the back and opening it up and actually being able to see the bone there and doing your procedure versus a percutaneous, which is making a small incision or a stab incision, but it can be a small incision where you need it to get to the body part, but you're not fully exposing the body part. So you can still have a two, three inch incision that is not open. It's percutaneous. You're not exposing that body part. So make sure that you understand those two. And then your other operative procedures, including fusions. A fusion may also be called arthrodesis. If you see arthrodesis, that's a fusion. A corpectomy is the removal of all or part of the vertebral body, usually performed with a discectomy. This is part of the fusion procedure and is not coded separately. Okay. There are several devices that are used when we do spinal fusions. So there is interbody fusion devices, and those can be a interbody fusion cage, a BAK cage, a peak cage, bone dowels, must specify interbody fusion device. So they have to tell you what they're using to code that. So it has to say one of those things to code it as an interbody fusion device. Your autogalous tissue substitute. So bone graft obtained from the patient during the procedure, bone grafts may be harvested locally using the same incision or from another body part with a separate incision. If they harvest a bone from a separate incision, that will require a separate code. Okay. Non-autogalous tissue substitute. So bone is harvested by a tissue bank from a cadaver. And then there's your synthetic substitute. So examples of that include demineralized bone matrix, synthetic bone graft extenders, and bone morphogenetic proteins or BMP. That's what falls under those devices in your ICD-10 procedure codes. Other operative procedures for fusions and arthrodesis, combinations of devices and materials for that spinal fusion. So if an interbody fusion device is used alone or in combination with other materials, like any type of bone graft, that procedure will always be coded to an interbody fusion device. That's your default if they use an interbody fusion device. If bone graft is the only device used, the code, the procedure, that's supposed to be procedure, sorry, is coded to non-autogalous tissue substitute or autogalous. So depending what they use. If they use a mixture, it will always default to autogalous. All right. So if they use both non and autogalous, you're going to default to autogalous. Your ICD-10 qualifiers for your spinal fusion. So you have anterior approach, anterior column. So that means that the patient is supine. They're facing up on the table. That incision is made on the front of their body, maybe the side, but the procedure is performed on the vertebral body or disc, all right, in the anterior column. So vertebral body or disc. Posterior approach, posterior column. Here you're looking at the patient is prone. So they're laying with their back up. The incision's made on the backside of their body. And this procedure would be performed on the vertebral foramen. So the posterior column, the vertebral foramen, the spinous process, the facets, or the lamina, okay. And then last, you have that posterior approach, but the anterior column. So again, now they are laying with their back up again. The incision's made on the backside of the body. And this procedure, again, would be on the vertebral body or the disc, okay. So those are your qualifiers for those fusions. So again, code each vertebral joint that is fused. So looking at your upper joints, you have that occipital cervical joint, a cervical vertebral joint. So that would be for one. Then you have cervical vertebral joint two or more. And then it falls into your cervicothoracic vertebral joint, a thoracic vertebral joint one. And then if they did fuse two to seven, and then thoracic joints eight or more. And then again, your lower joints is where your lumbar falls. And again, it would be that lumbar vertebral joint single, lumbar vertebral joint two or more, and then lumbosacral joint. So remember, if they fused your occipital cervical joint, you would have that code. And then say they, after that, they joined together C2 through C4, you would also have a second code for the cervical vertebral joints two or more. So just remember, make sure that you're coding everything appropriately. Again, your ORIF of the vertebrae, occasionally you will see an open reduction with internal fixation of a vertebrae. And if they do that, there are your codes for that ORIF of your upper or lower bones. Oh, all right, we have made it to quiz time. So according to the American Spinal Injury Association, Asia, the Asia, an Asia B injury indicates A, an incomplete injury, B, a complete injury, C, no injury, and D, a dislocation injury. I can't see what the percentages are at. See if we're ready to move on or not. Oh, here we go. Alrighty. All right. So the answer is a great job incomplete injury, either sensory but no motor function preserved below the lesion level. Great job, guys. A patient undergoes a fusion of C2 through C5 with an interbody fusion device, autogolous graft, and non-autogolous graft. The fusion device should be coded to A, an interbody fusion device, B, an autogolous graft, C, a non-autogolous graft, and D, there should be three different codes for this procedure, one with each type of device. Oh, there we go. All righty. Well, let's go. Answer is A, the interbody fusion device. So it looks like most went with that, we had a few others. But remember, interbody fusion device. When an interbody fusion device is used in combination with other graphs, any other graphs, interbody fusion device is coded. All right. This type of fracture involves the bilateral pars of C2. Is that a Jefferson fracture, a chance fracture, a Hangman's fracture, or none of the above? Bilateral pars of C2. Good job. Answer is C, a hangman's fracture. All right, good job, you guys did great with that one. A patient undergoes a spinal surgery for an epidural hematoma from T3 to T6 with fractures of the vertebral body, spinal process, and facet joints of T3, 4, 5, and 6. The surgery involves open decompression of the spine and fusion of all four vertebrae, so the vertebral body, facets, and spinal process, with a toggles bone graft and posterior approach. How many procedure codes would be involved in this surgery? So A1, B2, C3, D4. If you were coding this scenario, so a decompression for an epidural hematoma, right? Fusion of all four vertebrae, T3 to T6. All righty, let's see. Answer is three. Three. You would code that spinal decompression, so the release of that thoracic spinal cord open, the fusion of four thoracic vertebrae, both anterior, so the vertebral body and posterior columns, facets and spinal process, and then the posterior approach posterior column is that one, and then the other is posterior approach anterior column. So when you have a fusion in different parts, meaning you have the anterior column fused and the posterior column, it requires two different codes, okay, and then that release as well. So three. All right, I think this is our last one, and this is a patient undergoes a spinal surgery for an epidural hematoma. Wait, this the same one? Oh no, sorry. A patient undergoes a spinal surgery for, yeah, this does not look right. I don't know what happened. Hold on. That's not the right question, as you can see by the answer. Hold on. Let me just pull that up. Sorry guys, that for some reason is not the right question. I don't know how that happened. All right, well, we can't do this question. So questions, let me pull it up and see if it just didn't get copied over, right? Well, it's 52 anyway. We've got lots of, probably have lots of questions, I'm assuming. Yes, Robin, thank you very much. That was excellent, and I really have to say that Deb had even mentioned this, that this is an excellent sort of understanding and presentation and that trauma program managers should also see, because they need to understand the complexity of what the registry team does. And I think that this topic specifically is an excellent one, because I know myself, I get a lot of questions. There are some questions in the chat, so we have like seven minutes left. So I'm going to start from the top. So the first question is, what makes a burst fracture unstable? If you could just, I know you talked about it briefly, but a little bit of elaboration, and then does the provider need to say it's unstable to code it that way? So, yeah, I look for a physician to tell me that it's unstable. I wouldn't code it unless it's documented somewhere that it's unstable. I mean, certain types of fractures are obviously unstable, just that's what they are, but I don't code it that way unless someone tells me that I have an unstable fracture, because we always say it has to be documented in order to do it. And again, sometimes you can glean that too, if they're going to go to the OR. If it's unstable, they should be going to the OR, right? That's one of your key... And what was the other one? A burst fracture? Nope, that was it. Just clarify what exactly, what makes it unstable. Got it, got it. So yeah, what makes a burst fracture unstable? That's a good question. That's a good question. And I have to get a little bit more information before I answer that. I would think it just depends on where that burst went to make it unstable, right? Right, right. I would also imagine there'd be some clinical component, however they present clinically. Correct. I would agree. All right, great. Going to the part of the presentation where you talked about spondylolisthesis. If the physician or radiologist says fracture with spondylolisthesis, which would you code or do you code them both? Is it an all-in-one or is it separated? That's a really good question. And I am pretty sure, but I'm going to double check myself before I answer this right off the bat, but I am pretty sure that it is a fracture that we're going to code primary and that spondylolisthesis. Let me, so that I'm not sitting here looking this up, let me write this down and I'm going to get that back to Deb so that she can send it out to everyone that attended. Fantastic. The registry team are giving you a run for their money in it. No, this is great. They're a great question. No, it's helpful. All right. Are you ready for the next question? Yeah, go ahead. I'm just making a note for that one. Sure. So is there a code for retropulsion of the fracture into the spinal cord canal? Is there a specific code? No, that is a great question. And I think it's one that people kind of sometimes will look at and think, well, no. So what is the codable? Retropulsion is not a codable term, right? It's going to be, if that fracture went into the spinal canal, what is the injury? What did it cause? Did it cause a spinal injury? Did it cause a hematoma, you know, on that spinal cord? Did it cause maybe a tear or a laceration of the spinal cord? What is it causing? That's what you're coding. So the retropulsion itself is not codable, but what injury, you know, that caused. Perfect. Perfect. How would you code a distraction injury at C4 and C5? Now, the question was ICD-10 and AIS, knowing that you can't really talk too much about AIS, if you could just provide some direction. A distraction injury is, well, it depends. So again, I am one that does query the physicians a lot when they don't tell me what something is. Because what I want to know is like, what is the distraction injury? So I went over that. So a distraction injury, again, if I go back here a little bit and I go to those. Right there. So your chance, your chance fracture, right? A flexion distraction injury. So again, what is your flexion distraction injury is what you need to know. If they just say this patient has a distraction injury, you need to query them to find out, well, what is it? Right? You have extension teardrop, flexion teardrop, right? You've got your chance fracture, which is an unstable flexion distraction. So again, when they, if they're just telling you distraction injury, that's not enough to code, right? You need a little more than that. Absolutely. Agreed. All right. I, we're at, almost at the hour, but one more question here. If you have an epidural hematoma at the level of T3 with a fracture at T3 and no neurological deficits, and you also have a T4 fracture, you either code the epidural or the fracture at T3, but can you still code the T4? That's a wonderful question. Wonderful question. Somebody is super smart. So no, I mean, this is great. This is a great question. So whoever asked this question is correct. If you have a spinal hematoma, okay, at a fracture level and there's no neurologic deficits, you only code one or the other. So you have to choose, do you want to, what you want to code there, right? And then she's saying, in addition, you have a T4 fracture. You are still going to code the T4 fracture. If the, you know, you, you don't have anything else. You have the T3 with the epidural, you're still going to code a T4 then in that, in that case. Now, if that, you know, epidural hematoma is down through T4 as well, say it goes T3 through T6 level, and you have fractures at T3, T4, then you're, again, you're going to have to decide what you want to code. Do you want to code that epidural hematoma or do you want to code those two fractures? Yeah. That's a great, great question. That's a great question. Real quick, I'm going to squeeze a few in. How would you code the fracture of an osteophyte? You don't code the fracture of an osteophyte. It is not a codable injury. It's not, it's, it's not, it's nothing for, for us in trauma, it means nothing. So when you see an osteophyte fracture, ignore it, ignore it. That's what I say. All right. Well, I think that wraps up the questions. I want to thank you again, Robin. This was an excellent presentation. I, myself, got a lot out of it and clearly everybody was very engaged in your presentation. So thank you very much. I want to thank everybody for attending today. This is tremendous. The, the attendance today was fantastic. If you do have other questions or you'd like more information, please feel free to reach out to the TCAA and we will make sure that we engage Robin to get those. Yes, we'll do. Thank you so much for allowing me to present. It's always a pleasure. All right. Well, we will close today's webinar. Again, thank you, Robin. Thank you everyone for attending. Thank you to the TCAA for supporting this effort and have a great afternoon, everybody. Thank you.

spinal cord injuries

coding

registry perspective

Robin Schrader

spinal cord anatomy

coding principles

causes of spinal cord injuries

ASIA scale

types of spinal cord injuries

spinal fractures