Neurosurgery Coding Alert

Mastering terms and modifiers makes the difference

If you're bewildered by the mysteries of spinal instrumentation, take heart: Instrumentation claims are quite simple if you know whether the procedure is anterior or posterior, segmental or nonsegmental and when to apply a modifier. Our experts offer the following five tips to help you improve your instrumentation coding. 1. Select Instrumentation Codes by Type and Location When selecting among the spinal instrumentation codes (22840-22855), you should first determine the type of device the physician placed, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb. The two most common types of instrumentation are:

A. Anterior instrumentation (22845-22847), which attaches to the front portion of the spine or vertebral segment (in other words, toward the "center" of the body), and

B. Posterior instrumentation (22840, 22842-22844), which attaches to the back of the spine or vertebral segment. Look to the operative report for guidance: Generally, the type of instrumentation will correspond to the surgical approach (anterior or posterior). And, the surgeon's documentation should explicitly state the type of instrumentation he or she places. If the surgeon's operative report does not specify, be sure to ask.

Here's an easy way to determine segmental from nonsegmental: If the surgeon places posterior instrumentation, you must further determine if the device is segmental (22842-22844) or nonsegmental (22840).

The surest way to do this is to count the number of fixation points, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. If the surgeon attaches the instrumentation to the spine at only two points, the device is nonsegmental (regardless of the number of vertebrae spanned). If the surgeon attaches the device to at least three points (on three different segments), the instrumentation is segmental.

In some cases, the surgeon will place a metal cage or other prosthetic device for stabilization in an area where he has removed a large portion of the vertebra. This represents a third type of instrumentation, which you should report using 22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace). Report only a single unit of 22851, regardless of how many devices the surgeon places at one level, Sandham says. If the surgeon places devices on multiple spinal levels, however, you may report multiple units of 22851 (one unit for each individual spinal level).

Coding example: The surgeon places two cages at level T6. Report 22851 x 1. Alternatively, the surgeon places two cages at level T6 and a third cage at level T5. Report 22851 x 2. Some payers may require you to append [...]