Neurosurgery Coding Alert

Know the bundling and learn the descriptor changes.

You'll need to rethink how you're reporting your surgeon's arthrodesis services this year, thanks to combined codes and language changes in CPT®. Read on for advice on applying these updates and steer clear of denials for these spinal procedures.

Apply These 3 Bundling Issues

CPT® 2012 identifies the bundling of the codes 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with lateral transverse technique, when performed]) and 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) when performed together at the same level/interspace.

"While codes 22630 and 22612 were considered separately identifiable in the past (although there was formerly an NCCI edit for several quarters bundling the codes that was subsequently reversed), the frequency with which both codes were reported together was so high that the Relativity Assessment Workgroup of the Relative-value Update Committee required development of a combined CPT® 2012 code to reduce any potential overlapping work not accounted for by the multiple procedure rule," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Another important change in 2012 is that code 22633 and code 22634 identify primary and additional level codes involving interbody and lateral fusions performed at the same level. For example, a 56-year-old woman with L4-5 mobile degenerative spondylolisthesis and intractable back pain undergoes a posterior L4-5 interbody arthrodesis with an interbody cage placement, posterolateral arthrodesis of the facets at L4-5, posterior non-segmental pedicle screw instrumentation, and cancellous iliac autograft harvest for the fusion.

"You would report this as 22633, 22851 (Application of intervertebral biomechanical device[s] [eg, synthetic cage[s], methylmethacrylate] to vertebral defect or interspace [List separately in addition to code for primary procedure]), 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 20936 (Autograft for spine surgery only [includes harvesting the graft]; local [eg, ribs, spinous process, or laminar fragments] obtained from same incision [List separately in addition to code for primary procedure])," says Przybylski.

Also, going further in 2012, codes 22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) or 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]) apply as an interbody or a lateral fusion respectively when performed at any levels in addition to the primary combination codes 22633, as opposed to utilizing the primary procedure codes 22612 or 22630.

Summing up: If you are reporting an interbody and lateral fusion at one level, then you choose code 22633 and for subsequent procedures including interbody fusion, you select the additional level code as 22632. If your surgeon did a lateral fusion alone at the additional level, you report 22614.

Important change: The use of codes like 22612, 22614, 22630, and 22632 represent a significant shift in CPT® policy as you may no longer be using the primary procedure code when a different procedure is performed at a subsequent or different level.

You will see what procedure is being performed at each individual level. If you read that your surgeon did an interbody lateral fusion performed at a level, then you report code 22633. For subsequent procedures including interbody fusion, you report the additional level code 22632. If at the additional level, your surgeon also did a lateral fusion, you go in for 22614.

Documentation tip: Arthrodesis implies fusion and involves removing or shaving away the cartilage in a joint so as to facilitate the bones of the joint to grow and fuse together. In the codes above, pay attention to the terms 'vertebral segment' and 'interspace'. Remember, fusion will involve two vertebrae and the intervertebral space.

Mark the Change in Language in These Codes

In 2012, you will see a change in language in the codes 22610 (Arthrodesis, posterior or posterolateral technique, single level; thoracic [with lateral transverse technique, when performed]), 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with lateral transverse technique, when performed]) or 22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) for lateral fusions.

In 2011, the descriptor for these codes was as follows:

'Arthrodesis, posterior, posterolateral technique, single level, thoracic or a lumbar (with or without the lateral transverse technique)'

The new 2012 descriptor is: 'Arthrodesis, posterior, posterolateral technique, single level, thoracic or lumbar with lateral transverse technique, when performed.'

Rationale: "CPT® has been trying to eliminate "without" descriptors, since a procedure with a component will require more work than one without the same component. Since a single value must be attributed to any code, the more precise descriptor affords a better opportunity for a more accurate value," says Przybylski.

Decipher the Implications of the Terminology Change

The new descriptors specify that a posterolateral technique of any type can be performed in order to bill for the posterolateral fusion. Any combination of laminar fusion, facet fusion, or intertransverse fusion is considered a posterolateral fusion.