Stay Current with Spine Procedural Coding

Stay Current with Spine Procedural Coding

There are many 2017 CPT® code changes pertaining to spine procedures. Here’s a rundown of the most significant changes.

Removal of Moderate Sedation Inclusion

The moderate sedation symbol (¤) was removed from the vertebroplasty (22510-22512) and vertebral augmentation (22513-22515) codes. These codes no longer include moderate sedation, which can now be reported separately, as appropriate, using 99151-99157.

Interlaminar Epidural or Subarachnoid Injections

Two injection codes are deleted and replaced with four new codes to describe interlaminar epidural or subarachnoid injections. The differentiating factors between the four codes are two-fold:

1. The spinal region where the injection is performed; and

2.
Whether the injection is performed with or without imaging guidance.

The new codes are shown in Table A.

Table A

CPT® Code Descriptor
Cervical or Thoracic
62320 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62321                   with imaging guidance (ie, fluoroscopy or CT)
Lumbar or Sacral
62322 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62323                   with imaging guidance (ie, fluoroscopy or CT)

CPT® guidelines state not to report 62320-62323 with +77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure), 77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation, or 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

Injection Including Indwelling Catheter Placement

CPT® codes 62318 and 62319 are deleted. The four replacement codes are similarly differentiated by the spinal region, as well as use of imaging guidance, as shown in Table B.

Again, CPT® guidelines state not to report 62320-62323 with imaging codes +77003, 77012, or 76942.

Table B

CPT® Code Descriptor
Cervical or Thoracic
62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62325                   with imaging guidance (ie, fluoroscopy or CT)
Lumbar or Sacral
62326 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62327                   with imaging guidance (ie, fluoroscopy or CT)

Closed Treatment of Vertebral Process Fracture

CPT® 22305 is deleted because current clinical practice reflects a low utilization of this code. CPT® guidelines now instruct providers to use an evaluation and management (E/M) code for this service.

Posterior Interlaminar/Interspinous
Process Stabilization/Distraction Device

Category II codes 0171T and +0172T are deleted. Replacement codes are differentiated by whether decompression was also performed, as listed in Table C.

Table C

Point of Differentiation CPT® Code Description
With open decompression 22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level
+22868 second level (List separately in addition to code for primary procedure)
Without open decompression 22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level
+22870 second level (List separately in addition to code for primary procedure)

These codes do not describe procedures for arthrodesis or fusion devices; the devices are used for only spinal stabilization and/or distraction.

Like all open spine procedure codes, these codes include imaging guidance (e.g., fluoroscopy) as needed to perform the procedure. CPT® guidelines state that 22867-22870 may not be reported with other spine procedure codes including specific arthrodesis, instrumentation, and decompression codes. The CPT® codebook provides further guidance.

Intervertebral Device Code Changes

A major spine procedure code change was the deletion of +22851 and the creation of three new codes.

The most common code that spine surgeons will use is +22853 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure). This code may be used for anterior or posterior procedures; it is not limited to only anterior spine procedures.

CPT® clearly states that +22853 includes the placement of any anterior integral instrumentation (meaning the anterior plate is necessary to use with the device), when performed. This distinction was not clear with the old code (+22851). As a result, some incorrectly reported +22851 and +22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure), when only +22851 was appropriate.

The intervertebral device with an integrated anterior plate, also called a “low profile” or “stand-alone” device, is accurately reported using only +22853. It is incorrect to separately report +22845 if an integrated plate was used to secure the device into the interspace.

How will you know if the device should be reported using +22853 only, or using both +22853 and +22845? The spine surgeon should document in the operative report the specific trade name of the spinal implant so the correct code(s) are reported. You can also look up the device on the internet to see what it looks like and determine if it qualifies for one or two codes.

The remaining two intervertebral device codes are:

+22854 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

+22859 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

CPT® +22854 is used when an intervertebral device is placed into a corpectomy (removal of the vertebral body) defect and arthrodesis is performed. For example, a C6 corpectomy is performed with discectomies at C5-C6 and C6-C7 with preparation of the C5 and C7 endplates. An expandable titanium cage packed with bone graft for arthrodesis is placed into the corpectomy defect, and a plate is secured to C5 and C7. The expandable titanium cage is reported using +22854 because it was placed in a corpectomy defect and arthrodesis was performed.

The typical example of +22859 is a methylmethacrylate spinal reconstruction of a resected vertebral body where there is no arthrodesis.

Several instructional and add-on code parenthetical notes are added throughout the CPT® codebook to clarify the deletion of +22851 and the addition of these three new codes.

Define Approach and
Visualization for Spine Procedures

Within the Spine and Spinal Cord section of the Nervous System codes, CPT® 2017 provides new definitions of key terms and operative approaches to clarify code descriptors, as shown in Table D.

Table D

Approach Type of Visualization
Direct Light-based visualization; can be performed by eye, or with surgical loupes, microscope, or endoscope
Indirect Image-guided (e.g., computed tomography (CT), fluoroscopy), not light-based visualization
Percutaneous Image-guided procedures (e.g., CT, fluoroscopy) performed with indirect visualization of the spine without the use of any device that allows visualization through a surgical incision
Endoscopic Continuous direct visualization through an endoscope
Open Continuous direct visualization through a surgical opening

Spine surgical CPT® codes are presumed to be open, unless the code descriptor states otherwise.

Lumbar Endoscopic Decompression Code

CPT® 2017 adds new lumbar endoscopic decompression code 62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar. This code may be reported with modifier 50 Bilateral procedure when performed bilaterally.

This procedure is performed endoscopically, which CPT® now defines as having “continuous direct visualization” of the spinal structures through an endoscope.

This new code resulted in revising code 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar, also known as the percutaneous intervertebral disc decompression code, to remove the words “with the use of an endoscope.”

Percutaneous Decompressive
Laminotomy/Laminectomy

Two Category III codes were also revised to remove the words “with or without the use of an endoscope,” in accordance with the new definitions of operative approaches previously discussed:

0274T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic

0275T lumbar

Percutaneous procedures are image-guided without direct visualization of the spinal structures. Refer to the 2017 CPT® codebook for a complete listing of changes.

Kim Pollock

Kim Pollock

Senior Consultant at Karen Zupko & Associates
Kim Pollock, RN, MBA, CPC, CMDP, is a senior consultant and speaker with Karen Zupko & Associates, Inc., a physician practice management consulting and training firm based in Chicago, Ill. She is on the faculty for the American Association of Neurological Surgeons coding and reimbursement courses. Pollock has recently co-authored the book The Essential Guide to Coding in Otolaryngology.
Kim Pollock

About Has 3 Posts

Kim Pollock, RN, MBA, CPC, CMDP, is a senior consultant and speaker with Karen Zupko & Associates, Inc., a physician practice management consulting and training firm based in Chicago, Ill. She is on the faculty for the American Association of Neurological Surgeons coding and reimbursement courses. Pollock has recently co-authored the book The Essential Guide to Coding in Otolaryngology.

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