Realign Your Spinal Coding Skills
Here is what you need to know to avoid obsolete coding practices.
Over the past few years, CPT® coding for spinal surgical procedures has changed significantly. Have you kept pace? Let’s double-check to make sure you’re still reporting correctly.
When it comes to counting fusion levels, it helps to remember the “cream filling” analogy. If you think of the vertebral segment/interspace as an Oreo® cookie, a fusion between two vertebral bodies involves removing the disc space, or the cream filling in the cookie.
For example, if the surgeon documents posterior fusions of the L1-L5, you must count the disc spaces. In this case, there are four fusion levels: L1/2, L2/3, L3/4, and L4/5. This is reported using:
Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)
each additional vertebral segment (List separately in addition to code for primary procedure) x 3
A fusion is the joining of two vertebral bodies (the cookie part of the Oreo®). The AAOS Bulletin (August 2004) clarified that a fusion is the removal of the disc material between two vertebral bodies. CPT® Assistant (March 1996) addressed this issue, as well, and defined an example of L4/5 as one fusion level (e.g., 22612).
The same is true when coding interbody fusions: Count the structures being removed between the two vertebral bodies. If the surgeon performs transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) at L1-L5, for example, then there are four levels (L1/2, L2/3, L3/4, L4/5). This is reported using:
Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar
each additional interspace and segment (List separately in addition to code for primary procedure) x 3
If the surgeon performs double posterior fusions (interbody and posterolateral), then count the structures removed between the two vertebral bodies (L1-L5) — also four levels. This is reported using:
Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar
each additional interspace and segment (List separately in addition to code for primary procedure) x 3
Nerve Root Decompression
When reporting nerve root decompression, you must know how many nerve roots were decompressed. For example, if the surgeon documents nerve root decompression of L4/5, then you must clarify whether it was the L4 and L5 nerve roots, or only the L4.
Surgeons documentation for 63045-63048 should clearly state something like, “Nerve root decompressions were performed at the L2, L3, L4, and L5 nerve roots.” And document a paragraph for each in the operative note, stating that attention was directed to the decompression of the L3 nerve root, etc. This (more thorough) documentation helps to support the coding and it’s great information to have in the event of an appeal.
Recently, the Center for Medicare & Medicaid Services (CMS) — via the National Correct Coding Initiative (NCCI) — bundled 63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar and +63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) into 22630 and 22633. This change makes decompression unbillable if performed at the same level(s) as arthrodesis.
The NCCI edits allow nerve roots decompressed at different levels from the arthrodesis to be reported separately. For example, a surgeon performs posterolateral fusions at L1-S1, with an interbody fusion at L5/S1 (22630, 22614 x 4) with nerve root decompressions of L3 and L4 nerve roots. In this case, you may report 63047 and 63048 with modifier 59 Distinct procedural service appended because the decompressions were not done at the same level as the interbody arthrodesis (22630).
Following efforts by the American Association of Neurological Surgeons (AANS), North American Spine Society (NASS), and American Academy of Orthopaedic Surgeons (AAOS), CPT® Assistant (May 2018) clarified that decompression of the nerve roots is not considered to be a component of arthrodesis codes 22630/22633:
On further analysis of this issue, it was demonstrated that this recommendation was inconsistent with previously published CPT® Assistant advice, which is that codes 22633 and 63047 may be reported for the same interspace when additional work is required to complete a decompression at a single spinal level. It is also appropriate to report codes 22633 and 63047, if the two procedures are performed at different interspaces. Modifier 59, Distinct Procedural Service, should then be appended to indicate that these are two distinct procedures. This correction aligns the coding advice with historical precedent published prior to the incorrect revisions in advice given in the October 2016 FAQ.
If you receive denials when reporting 63047/63048 with 22630/22633 at the same level(s) from payers who do not follow NCCI edits, get a copy of the May 2018 CPT® Assistant to use as evidence in your appeal process.
The most common instrumentation codes are those for either anterior (22845-22847) or posterior (22842-22844) approaches. In particular, +22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) and 22849 Reinsertion of spinal fixation device can cause problems if used inappropriately.
The phrase “across one interspace” in the descriptor for 22840 can be misleading. CPT® Assistant (July 1996) stated, “If there are less than three vertebrae involved, then code 22840, Posterior non-segmental instrumentation (eg, single Harrington rod technique), would be reported, since it indicates a non-segmental instrumentation involving two vertebrae.”
The January 2011 CPT® Assistant gave further insight, explaining:
Code 22840 is used to report the placement of non-segmental instrumentation. Non-segmental instrumentation is defined as fixation at each end of the construct and may span several vertebral segments without attachment to the intervening segments. Fusion of two adjacent vertebrae is considered non-segmental.
Use 22849 if the surgeon removed and reinserted instrumentation at the same level(s). For example, if the surgeon removes instrumentation at T7-L3 and replaces it at the same levels (T7-L3), 22849 is the only instrumentation code reported. But if the surgeon removes instrumentation from T7-L3 posterior and reinserts instrumentation at T10-L3 posterior (six levels), proper coding is +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).
CPT®, CMS, NCCI, and AAOS agree that the removal is considered inclusive in the insertion codes for the same operative session. CPT® guidelines remind you not to report instrumentation removal codes with insertion instrumentation codes for the same session. Do not report the removal and reinserting of a cage with 22849.
The use of cages as instrumentation are reported using:
- +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)
- +22854 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) 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)
The difference between these three codes is the reason why the cages are placed:
- Report 22853 when a metal cage is placed for an interbody fusion (either anterior or posterior).
- Report 22854 when a metal cage is placed with corpectomy and interbody fusion.
- Report 22859 when a vertebral body is removed, and a custom-made metal cage is inserted but no interbody fusion takes place — such as when a patient has had a malignancy removed from the vertebral body.
Because many cages now have anchoring screws/devices to hold the cage in place, there must be accurate documentation of a separate and unattached anterior plate/screws being placed to bill both instrumentation codes.
AANS recently illustrated to CMS that there should not be an edit between 22853 and 22854 when also placing anterior instrumentation (22845-22847). As a result, Chapter 4 of the NCCI guidelines now says:
CPT codes 22853 and 22854 describe insertion of interbody biomechanical device(s) into intervertebral disc space(s). Integral anterior instrumentation to anchor the device to the intervertebral disc space when performed is not separately reportable. It is a misuse of anterior instrumentation CPT codes (e.g., 22845-22847) to report this integral anterior instrumentation. However, additional anterior instrumentation (i.e., plate, rod) unrelated to anchoring the device may be reported separately appending an NCCI-associated modifier such as modifier 59.
Your surgeons can help to clarify that the anterior plate/screws are unrelated to the cage by naming the manufacturer of the device, along with the manufacturer’s name of the placed plate/screws. Naming the inserted products enables you to research any connecting components and the payer/insurer to verify if separate payment is allowed. There are several internet sites that name the manufacturer or device: One such site is Medical Expo, where you can select the location on the spine (cervical, thoracic, or lumbar) or the approach (anterior or posterior), along with the manufacturer.
If the cage and anterior plate are connected, do not bill both the cage and the plate. AAOS has said that when two CPT® codes are bundled and only one can be reported, normally you should report the code with the higher work value. NCCI guidelines also mention this relationship: Regarding 22853/22854 and 22845-22847: 22845-22847 are the higher value codes, but NCCI lists them as column 2 codes with 22853/22854 (in most cases, the column 1 codes are the higher-valued codes).
If your surgeon is using allograft cages, report +20931 Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure), per the February 2005 CPT® Assistant.
This is just a portion of the complex area of spinal procedure coding, but it’s a start. If you code these procedures, or would like to, it’s essential that you stay up to date on all of the changes to related codes, guidelines, and determinations.
Margie Scalley Vaught, CPC, COC, CPC-I, CCS-P, PCE, MCS-P, ACS-EM, ACS-OR, has more than 35 years’ experience in the healthcare arena in positions from nurse’s aide to ward clerk and medical transcriptionist to office manager. She is a recognized AAPC-approved PMCC Instructor and is a member of MGMA/ACMPE, AAOE, Society for Clinical Coding (SCC), and AHIMA. Scalley Vaught has also provided testimony regarding correct coding issues and compliance in fraud and abuse cases. She is a member of the Olympia, Wash., local chapter.
A great resource book for spinal coding is from NASS, “Common Coding Spinal Scenarios 2018” (www.spine.org). This publication (which is updated yearly) provides examples and wording for many common spinal procedures.