Spinal Fusion Coding Begins with Successful Approach
By G.J. Verhovshek, MA, CPC, director of Clinical Coding Communication
To report spinal arthrodesis accurately, coders must distinguish among the various approach procedures the surgeon may select. Broadly speaking, these approaches fall into three categories: anterior, posterior, and lateral.
During an anterior approach, the surgeon places the patient supine (lying face up) and accesses the spine through an incision in the front of the body.
The transoral or extraoral anterior approach to the upper cervical vertebrae (22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process), for instance, occurs through the mouth itself, as illustrated on page 90 of the AMA’s CPT® 2008 Professional Edition.
To access the cervical vertebrae below C2 via anterior approach (22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2), the surgeon makes an incision in the neck, just below the jaw line.
For lumbar access by anterior approach (22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; lumbar), the surgeon places the incision over the abdomen, reaching the spine through either a transperitoneal (through the abdomen) or retroperitoneal (behind the abdomen) exposure. Surgeons commonly refer to this type of procedure as an anterior lumbar interbody fusion (ALIF).
Anterior approach to the thoracic vertebrae (22556 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; thoracic) likewise involves an access through an incision on the front of the body, although the exact location of the incision may vary according to the vertebrae the surgeon addresses.
Codes 22554 (cervical), 22556 (thoracic), and 22558 (lumbar) describe an interbody technique in which the surgeon places a prosthetic device between adjacent vertebrae in a space previously occupied by the intervertebral disc. The actual fusion then occurs between the bony endplates of the vertebrae. In preparation for fusion, the surgeon must remove the intervertebral disc almost entirely, and this minimal discectomy is an included component of 22554-22558. Code separately for placement of bone grafts (20930-20938) and instrumentation (22840-22851), however.
Be careful to count interspaces, rather than individual vertebrae, when reporting 22554-+22585. If the surgeon fuses T8 to T9, for instance, arthrodesis occurs at one level (the T8/T9 interspace, even though it involves two vertebrae. Similarly, a fusion from L1 to L3 would involve two levels (L1/L2 and L2/L3).
To claim anterior interbody arthrodesis, select a single primary level code, by spinal region (cervical, thoracic, or lumbar), for the initial level the surgeon treats. For each additional level beyond the first—regardless of spinal region—report add-on code +22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure).
In those cases when the surgeon crosses spinal regions—from the thoracic to lumbar region, for instance—select a single initial level code and report +22585 for the additional levels. In this code set, the Centers for Medicare & Medicaid Services (CMS)
assigns the greatest number of relative value units (RVUs) to the thoracic procedure, 22556. Select the thoracic code as primary when the surgeon crosses from one spinal region to another during anterior interbody arthrodesis.
For example, if the surgeon prepares interspaces T12-L3 for anterior fusion, report 22556 for the initial level (T12/L1) and +22585 x 2 for the additional levels (L1/L2 and L2/L3). Select 22556, rather than lumbar code 22558, as the primary level because it is the higher-valued procedure.
A posterior approach gains access to the spine through an incision in the back (or the back of the neck) with the patient prone or face down.
In the lumbar region, the surgeon can perform an interbody fusion via posterior approach. This procedure is commonly called a posterior lumbar interbody fusion (PLIF).
As with the anterior interbody procedures, report PLIF procedures per interspace (rather than per vertebra) that the surgeon addresses. Once again, these procedures include necessary discectomy and/or laminectomy, but you may code separately for same-session bone grafts and instrumentation.
For the initial PLIF level, report 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar. For each additional interspace the surgeon treats beyond the first, claim add-on code +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 instance, for a PLIF spanning interspaces L2/L3, L3/L4, and L4/L5, you would report 22630 and +22632 x 2.
The remaining posterolateral or posterior techniques places the bone graft between the transverse processes in the back of the spine, within the facet joints or along the lamina. Surgeons often will fix the vertebrae in place with screws through the pedicles or facets, and/or by placing wire through the facets or spinous processes of each vertebra. The screws or wire may attach also to a metal rod on each side of the vertebrae. An open TruFUSE® procedure, for instance, describes a method of performing posterior fusion below C2 using an allograft.
Once again, you may report bone grafting and instrumentation placement separately with the posterolateral or posterior arthrodesis codes.
For fusion of cervical vertebrae above C2, you will select either 22590 Arthrodesis, posterior technique, cranicervical (occiput-C2) or 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2), depending on the extent of the fusion and the precise vertebrae involved (see figures 3 and 4).
For posterior or posterolateral fusion below C2, you will select a single primary level code 22600-22612 to describe the initial level the surgeon treats, followed by add-on code +22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) for each additional level beyond the first that the surgeon addresses (see figure 5).
If the surgeon crosses regions from the cervical to thoracic region during posterior or posterolateral fusion, report 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment as the primary level code and +22614 for each additional level. If the surgeon crosses regions from the thoracic to the lumbar region, claim 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) as the primary level, again using +22614 for each additional level beyond the first. Both the cervical code (22600) and the lumbar code (22612) reimburse at a higher rate than the thoracic procedure, 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique).
Unlike other arthrodesis codes, you should count procedures performed via a posterior or posterolateral approach (22600-22614) per vertebral segment rather than per interspace. For instance, a C3-C4 fusion involves two vertebrae, and represents two units of service (22600 x 2) rather than one. Similarly, for non-interbody posterior fusion from T12 to L2, you would report 22612 (for L2) and 22614 x 2 (for L1 and T12).
During a lateral extracavitary approach, the surgeon usually positions the patient on his or her side and begins an incision vertically over the spinous process, advancing slightly below the spinal level(s) to receive fusion, then turns the incision sharply to follow the general direction of the ribs (the resulting incision resembles an “L”). This allows lateral exposure of the vertebral elements without having to enter the thoracic cavity (thus, an extracavitary approach). The AMA’s CPT® Changes 2004: An Insider’s View further clarifies, “The lateral extracavitary approach is unique … requiring performance of resection of the ribs, pleura, and peritoneum, [and] dissection of spinal/paraspinal tissues to access the vertebral bodies/discs.”
Like 22554–+22585 and 22600–+22632, the codes for lateral extracavitary approach describe an interbody procedure, in which the surgeon performs a minimal discectomy to prepare the interspace for prosthetic placement. Report these procedures per interspace the surgeon prepares. As with other interbody approaches, the minimal discectomy is an inclusive part of the procedure, but you may report bone grafts and instrumentation separately, when performed.
For the initial thoracic level the surgeon treats using lateral extracavitary approach, you should report 22532 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than decompression); thoracic. For each additional level the surgeon treats beyond the initial thoracic level, report add-on code +22534 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure).
For instance, if the surgeon prepares interspaces T2-T6 for arthrodesis by lateral extracavitary technique, report 22532 (for interspace T2/T3) and +22534 x 3 for the remaining interspaces (T3/T4, T4/T5, and T5/T6).
For procedures contained to the lumbar region, code 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than decompression); lumbar for the first level the surgeon treats, with one unit of +22534 for each additional level. Note that the surgeon crosses regions from the thoracic to lumbar region, cite the thoracic code (22532) as the primary level because it reimburses at a higher rate than lumbar code 22533.
The extreme lateral interbody fusion (XLIF) is a recently-developed, minimally-invasive technique for lumbar spinal fusion. The surgeon makes two small incisions: The first directly over the side of the waist (through which the surgeon performs the procedure), and the other slightly behind the first, toward the back muscles (through which the surgeon guides the approach). Under fluoroscopic guidance and with the aid of a special retractor, the surgeon removes the intervertebral disc at the targeted level(s), then fills the space with bone graft and/or a polyetheretherketone (PEEK) cage, metal, or other material. Following placement of the cage, the surgeon also may place a lateral plate through the same incision, or may choose to place posterior pedicle screws via minimally invasive techniques.
Despite the use of lateral in its name, XLIF is more appropriately described as an anterior retroperitoneal approach (albeit one that uses a specialized retractor). To report these lumbar interbody fusion procedures, report ALIF code 22558.
Note that at least one insurer (Cigna) has issued a non-coverage decision for XLIF because the technique “is considered experimental, investigational or unproven.”
Combined or 360 Degree Approaches
In some cases, the surgeon may perform either PLIF (22630) or ALIF (22558), along with a posterolateral fusion (22612), to stabilize the spine from both the front and back. Surgeons commonly refer to either combination as a 360 degree fusion.
If your surgeon performs and documents a 360 degree fusion, you may report either 22630 or 22558, as appropriate, along with 22612. The National Correct Coding Initiative (CCI) does not bundle or list these procedures as mutually exclusive. As such, you shouldn’t need to append any modifiers to bill a 22630/22612 or 22558/22612 combination.