Partial or Complete What Do Those Words Mean?
By Tammye Harber, CPC, CPC-H Senior Healthcare Consultant Ellis Medical Consulting Inc.
Webster’s dictionary defines the term partial as “relating to, being or affecting only a part; not total; incomplete.” Webster’s also defines the term complete as “having all necessary or normal parts, components, or steps; entire; absolute; total.” How do these terms — partial and complete — apply to us, specifically when performing an anterior vertebral corpectomy (also known as an anterior cervical corpectomy)? And, how do the corpectomy procedures, described in codes 63081 63091, differ from the discectomy procedures, described in codes 63075-63077?
So, when do we code a corpectomy as opposed to a discectomy? Where do the terms partial or complete leave a coder and physician? We are faced with these types of troubling questions:
• What is the quantity of partial that constitutes the corpectomy and not an anterior cervical discectomy?
• A discectomy is the removal of part of the disc that has prolapsed, bulged or ruptured, and which is causing pressure on spinal nerves; the material removed frees the nerves from pressure and irritation
• A corpectomy is the removal of part of the vertebra and adjacent disc to decompress the spinal cord and nerve roots; while the approach may be similar to a discectomy, the incision is larger because of the extensive work involved AND the defect created by the corpectomy must be reconstructed with an appropriate fusion technique
• Would it help to have a guideline that stipulates an anterior cervical discectomy as the placement of a seven millimeter graft, although a graft is not always necessary, and an anterior cervical corpectomy if a nine or 10 millimeter graft is placed?
There are factors that also help provide the key to differentiating between the coding of a corpectomy or a discectomy. Typically, a corpectomy is combined with an arthrodesis, and the procedure includes the insertion of a graft or a prosthetic device into the defect. The soft tissue and osteophytes are removed from the vertebral body, so the plate sits on the anterior cortex. Discectomies are completed as part of the corpectomy, and the partial or complete corpectomy is performed to decompress the spinal cord and nerves. Bone dimensions of the corpectomy site are measured for the graft; bone from the vertebral corpectomy may be used as graft material, placed as an autograft, along with allograft material.
Types of Corpectomy
The anterior cervical corpectomy also comes with the arthrodesis (fusion), graft and instrumentation. The vertebral corpectomy is often performed using a transverse incision and the disc above and below the vertebral body is excised. The endplates are removed and the section is prepared for graft. The graft can be coded separately. This cervical corpectomy procedure generally involves cervical vertebra C3 to C7 and is often done for stenosis, compression or to remove bone spurs (osteophytes). The vertebral body and adjacent intervertebral discs are removed for decompression of the spinal cord and spinal nerves. If needed, anterior instrumentation may be used for additional support while the spine fuses.
Still Left with the Question
While the extent of the procedure may define the difference between a discectomy and a corpectomy, we are still left with the original debate: partial vs. complete. CPT 63081 describes the procedure as follows: Vertebral Corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve roots(s); cervical, single segment The description of corpectomy, as shown in the above code example, fails to specify the amount of vertebral body for resection, other than by the terms partial or complete. The actual quantity is not defined by guidelines either by the Centers for Medicare or Medicaid Services (CMS) or the American Medical Association (AMA). There is no Medicare National Coverage Determination for this procedure. The recommendations for physicians performing the surgery vary, and may include certain percentages such as 50 percent of the cervical vertebral body must be removed for the procedure to be considered a corpectomy.
A corpectomy is more extensive than a discectomy and the risks are greater, especially with respect to neurological issues, bone grafting and bleeding. Since CPT does not differentiate between partial and complete, the corpectomy codes can be applied regardless of quantity. The problem, of course, is the amount of time the physician spends in relation to the work required. In the future, perhaps, the AMA or CMS will provide the guidelines and the work will be adjusted by code. Talk to your physician regarding the amount of vertebral body removed.
The coding for a corpectomy includes the following procedures that can be reported separately:
• To report the bone graft procedures (codes 20930-20938), do not append the modifier 51
• The type of graft to be coded will be based on the physician’s documentation
• The instrumentation used is based on the number of vertebral segments. For example, 22845 (2 to 3 vertebral segments), 22846 (4 to 7 vertebral segments), or 22848 (8 or more vertebral segments) involved
• Due to the greater risk of a corpectomy, the surgeon may monitor spinal function via Somatosensory Evoked Potentials (SSEP), which involves a device that generates electrical impulses to measure the brain’s response to the signal. The SSEP (95927, head and trunk) is reported separately. Tammye Harber is a health care consultant with Ellis Medical Consulting Inc., since May of 2006. For 15 years prior to that she was a coder and reimbursement specialist for a large metropolitan multi-specialty physician practice. Harber has worked in many specialties. Her coding and reimbursement experience extends into several specialties, including neurosurgery, pain management, anesthesia, radiology/interventional radiology, endovascular procedures, incident-tobilling for physician extenders, and evaluation and management coding for physician services.
List A shows the items that are included in the corpectomy, and which cannot be billed separately. List B shows the items that can be billed separately from the corpectomy, although it’s important to check the documentation for verification.
List A – NOT billed separately
• Local infiltration of medications
• Suture removal
• Surgical approach
• Wound culture
• Intra-operative photos
• Video recording
• Imaging or monitoring equipment by the physician or assistant
• Placement of drains and catheters
List B – Billed Separately
• Harvesting and insertion of grafts (20930-20938)
• Arthrodesis (22554 and/or 22585)
• Instrumentation (22845-22847) Medicare’s global period is 90 days. The anterior corpectomy procedure performed at a single level will be coded as 63081, 22554-51, 22585, 22845, 20938 and, in some cases, 20936. The use of an operating microscope (69990) may be reported, if applicable (again, check your documentation).