Complete Spinal Fusion Coding Includes Grafting and More

Part 2 in spinal series

By G. John Verhovshek, MA, CPC
Spinal fusion involves multiple steps beyond those described by arthrodesis codes 22532-22632, including bone grafting (20930-20938) and instrumentation placement (22840-22851). For complete coding, you should report these additional procedures separately. When extensive decompression accompanies arthrodesis, you may report the procedures independently.

Three Questions Discern Spinal Bone Graft Codes

To select an appropriate spinal bone graft code, the available documentation must allow you to answer at most three questions:
1. Was the graft taken from the patient’s body (an autograft) or from another source (allograft)? If documentation includes bone harvesting, an autograft code is appropriate. Allografts include all prepared grafts, such as Cornerstone or Medtronic Verte-Stack, or tissue taken from a bone bank.
2. If the graft was taken from the patient’s body, did the surgeon have to create a new incision to remove the donor tissue? Bone tissue taken from the ribs, spinous process, or laminar fragments is “local.”
3. Was the graft a single piece of bone (structural), or did it consist of several—or many—smaller pieces (morselized)? For example, along with posterior cervical laminectomy, the surgeon may pack morselized bone in open areas on either side of the spine and in the facet joint spaces to promote new bone growth.
These three questions help you easily discern among the spinal bone graft codes.
For example, suppose the surgeon performs a posterior lumbar interbody fusion (PLIF) for stenosis (724.02 Spinal stenosis; lumbar region) and spondylolisthesis (738.4 Acquired spondylolisthesis) at L1-L2 and L2-L3. She harvests bone from the iliac crest, via a separate incision, to prepare and place a morselized graft at each interspace c m.
You would report 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar for arthrodesis at the first interspace, and +22632 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure) for the additional interspace.
You would report +20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) for the harvest, preparation, and placement of the morselized graft. You should report any spinal graft code only once per procedure, regardless of how many areas the surgeon treats with that same type of graft.
Note that all spinal bone grafting codes 20930-20938 include graft shaping or preparation, when required, and all autograft codes include graft harvesting. You would not code separately for either of these services.
According to the 2009 National Physician Fee Schedule Relative Value File, you may not append modifier 50 Bilateral procedure, or modifiers 62 Two surgeons, 80 Assistant surgeon, 81 Minimum assistant surgeon or 82 Assistant surgeon (when qualified resident surgeon not available) to spinal graft codes 20930-20938.
CPT^® designates spinal bone graft codes as modifier 51 Multiple procedures exempt, meaning they should be paid at the full fee schedule amount when reported as additional procedures. Be aware, however, that Medicare designates graft procedures +20930 Allograft for spine surgery only; morselized (List separately in addition to code for primary procedure and +20936 Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) as status “B” codes. As such, Medicare payers will always bundle these codes into payment for other services. Third party insurers do not necessarily follow this convention.

Look to Surgical Approach When Reporting Spinal Instrumentation

As with bone grafts, separately billable instrumentation placement generally accompanies arthrodesis. For instance, in the aforementioned PLIF with morselized autograft example, the surgeon also may have fixed pedicle screws at two points to stabilize the spine further.
If the surgeon places a metal cage or other prosthetic device, such as a threaded bone dowel, in the intervertebral space, you will report +22851 Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure).
You should report only a single unit of 22851, regardless of how many devices the surgeon places at a single level. If the surgeon places devices on multiple spinal levels, however, you may report multiple units of 22851 (one unit for each individual spinal level).
When coding for instrumentation that spans across several vertebral segments using rods, cages, plates, wires and/or other mechanical devices, you must determine whether the device is anterior (attached to the front of the spine or vertebral segment, facing the front of the body) or posterior (attached to the back of the spine or vertebral segment, facing the back of the body). Anterior instrumentation usually involves application of plates screwed directly onto the vertebrae, whereas posterior instrumentation involves placement of rods or other apparatus that grip the lamina or are screwed into the pedicles. Generally, the type of instrumentation will correspond to the surgical approach (anterior or posterior) the surgeon selects.
You will claim placement of anterior instrumentation using +22845 Anterior instrumentation; 2 to 3 vertebral segments, 22846 Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) and +22847 Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure), depending on the number of vertebral segments spanned.
If the surgeon places posterior instrumentation, you must further determine whether the device is segmental (22842-22844) or nonsegmental (+22840 Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)).
Nonsegmental posterior instrumentation attaches to the spine at two points only—the proximal and distal portions (top and bottom) of the rod or other device. You may report placement of nonsegmental posterior instrumentation using +22840.
Segmental posterior instrumentation attaches to the spine at three or more points, including the proximal and distal portions of the rod or other device. You may describe placement of segmental posterior instrumentation using +22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure), +22843 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments) (List separately in addition to code for primary procedure), or +22844 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure), according to the number of vertebral segments spanned.
Be cautious when counting vertebral segments, keeping in mind that a single interspace lies between two vertebral segments. For instance, the span C6-T2 contains four vertebral segments (C6, C7, T1, and T2) and three vertebral interspaces (C6/C7/C7/T1, and T1/T2). To report anterior instrumentation across this span, you would choose 22846, which describes four to seven vertebral segments, rather than 22845, which describes two to three vertebral segments.
CPT^® defines spinal instrumentation procedures as inherently bilateral, so you should not apply modifier 50 to any spinal instrumentation codes. As with spinal bone grafts, all codes describing instrumentation placement are exempt from multiple-procedure (modifier 51) adjustments, according to CPT^®.
For example, a complete spinal fusion might include:

• L4/L5 Discectomy
•  L5/S1 Discectomy

• L4/L5 Transforaminal interbody fusion, posterior interbody technique
• L5/S1 Transforaminal interbody fusion, posterior interbody technique

Morselized autograft, obtained from local incision

• L4/L5 Interbody cage placement
• L5/S1 Interbody cage placement
• L4, L5, S1 Bilateral pedicle screw instrumentation

You would report the arthrodesis at two interspaces using 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar and +22632 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure).
In this case, the discectomy to prepare the interspaces at L4/L5 and L5/S1 is included in the arthrodesis, although a more extensive discectomy could be separately coded, when justified (see below for more information).
For the morselized autograft, you would report 20937.
For placement of the interbody cage at the first level, you would report 22851. Because cage placement occurs at a second level, you may also report a second unit of 22851 with modifier 59 Distinct procedural service appended. Modifier 59 shows the payer that you addressed separate levels.
For the pedicle screw instrumentation, you should report 22842. Remember, even though the instrumentation was bilateral, you would not append modifier 50.

Code Separately More Than Minimal Decompression Services

Arthrodesis may include related procedures such as minimal laminectomy and/or discectomy to prepare the interspace, as indicated in the individual arthrodesis code descriptors. Codes 22554-22585 and 22630-22632 describe scrapping away of the disk just enough to make room for graft material.
In some cases, the surgeon may perform a more than minimal (more extensive than usually associated with arthrodesis) discectomy or laminectomy. In these cases, separate coding for the decompression (for instance, 63047, Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (spinal or lateral recess stenosis)), single vertebral segment; lumbar) with modifier 59 may be justified.
To support a separate service, the surgeon’s documentation should highlight decompression of neural elements and removal of fibrovascular scar tissue over the dura (for instance, the posterior longitudinal ligament), removal of disc material on the far lateral sides, with foraminotomy, and/or necessary removal of osteophytes (bone spurs).
 

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