Neurosurgery Coding Alert

Scenario illustrates the intricacies of cervical disorder treatments.

Patients who have cervical disc disorders can be a handful for neurosurgery providers. Once they figure out the patient’s condition, they have to decide how to treat it.

These claims often prove difficult to pin down because they often involve multiple codes, and could include more than one visit to the provider.

Help’s here: Check out this cervical disc disorder scenario, courtesy of Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois. The scenarios all occur sequentially to the same patient, until the surgeon performs anterior cervical discectomy and fusion (ACDF) for a cervical disc disorder.

The Case

Encounter 1: A new patient reports to the neurosurgeon complaining of pain in the left upper back and shoulder blade down the left arm, with numbness and tingling in the thumb and index finger. A three-view X-ray of the cervical spine shows narrowing in the C5-C6 area. The provider then performs a magnetic resonance imaging (MRI) of the cervical spine without contrast. The provider prescribes the patient a DosePack and gives an order for physical therapy two to three times a week for four weeks. (The physical therapy occurs at a different provider’s office). Notes indicate a level-two evaluation and management (E/M) service occurred during the encounter.

Encounter 2: The patient returns to the surgeon five weeks later, saying that the physical therapy was not helping. A repeat MRI without contrast shows disc herniation at C5-C6. The provider schedules surgery and prescribes medication. Notes indicate a level-four E/M service.

Encounter 3: The next day, the surgeon performs anterior cervical discectomy and fusion (ACDF) at C5-C6 with cage insertion, anterior instrumentation, and demineralized bone matrix cancellous allograft. Encounter notes indicate that the plate and screws (anterior instrumentation) are a separate implant and not components of a standalone interbody device.

The Coding

Encounter 1: You should report:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) for the E/M service.

Encounter 2: You should report:

• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for the E/M with modifier 57 (Decision for surgery) attached to show that the E/M led the surgeon to schedule surgery the next day.

Encounter 3: You should report:

• 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) for the ACDF;
• +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)) for the cage insertion;
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)) for the anterior instrumentation; and
• +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)) for the demineralized bone matrix cancellous allograft.