Neurosurgery Coding Alert

Consider discectomy and facetectomy bundled in interbody fusion.

Spinal coding may pose a challenge as your surgeon often does more procedures than one, requiring you to proceed one step at a time to capture all services and accurately assign the codes. Let the 2-step process provided in the following case study guide you to more efficient spinal coding.

Example: Take a look at this sample procedure list an operative note provided by a Missouri Neurosurgery Coding Alert reader: For a patient with a preoperative diagnosis of lumbar spondylosis, the surgeon did the following:

• Left L4-5, L5-S1 facetectomy with hemilaminectomy of L5 and redo decompression L5-S1 on the left
• L4-5, L5-S1 left transforaminal interbody arthrodesis with allograft and autograft
• Segmental pedicle screw instrumentation L4 to S1 bilaterally
• Right sided posterior and facet arthrodesis with allograft and autograft
• Intraoperative electrical monitoring, intraoperative 3D imaging

Operative note: "The patient's lumbosacral region was prepped and draped in the usual sterile manner. Incision was made incorporating the previous incision over the L5-S1 region extending cephalad.... The deep fascia was incised and the paravertebral muscle was retracted laterally utilizing the subperiosteal reflection. On the left side there was abundant amount of scar tissue which had to be loosened to accomplish the dissection lateral to the facet regions and into the sacral alar region.  This was accomplished bilaterally. Then the laminotomy defect on the left at L5 from previous surgery was identified. Sharp curettes were used to clear the dura from the surrounding edges and then using thin plate Kerrison's and the Midas Rex drill, the decompression was done.

Bone was saved from the decompressive part of the procedure for later arthrodesis and essentially a hemilaminectomy of L5 and a laminotomy of L4 was performed as well as facetectomy at L4-5 and L5-S1. The thecal sac was identified along with the exiting nerve roots at these levels. The L5 nerve root was identified along its entire course as the patient had L5 radiculopathy. At L5-S1, there was abundant scar tissue but no disc herniation per se. Discectomy was performed. At L4-5, there was subligamentous disc herniation as well as lateral recess stenotic changes impinging upon nerve roots. This was decompressed with the operation. At both levels, transforaminal interbody fusion discectomies were performed using the Medtronic instrumentation and scrapers and sizes cleaning out the disc nicely.

At L5-S1, an 8 mm graft X 26 was deemed to be the correct size and at L4-5, a 10 mm graft X 26 was deemed to be the correct size. Under fluoroscopic guidance at both levels using the typical procedure, allograft spaces of this size were then tamped into the disc space and recessed. Attention was then turned to the pedicle screw instrumentation. Under fluoroscopic guidance entry holes were placed at L4, L5 and S1 regions and using standard technique of tapping the pedicle and placing pedicle screws. During this procedure, EMG monitoring was used throughout and was not abnormal at any level.

Then the patient had 3D reconstructive imaging with the O-arm and the pedicle screw instrumentation appeared satisfactory. Further attention was turned to the arthrodesis. On the right side, the posterior laminar regions as well as the facet regions were decorticated and the remainder of the patient's own allograft and demineralized bone matrix was placed in this region. It should be mentioned that at L4-5 patient's allograft was placed in the bed of the disc space before tamping the allograft interbody spacer in place. Then rods were placed into the pedicle screws on either side and tightened in a standard fashion and locked. Attention was then turned to closing."

Step 1: Check Documentation for Spinal Procedures

You report the arthrodesis at L4-L5 and L5-S1 with 22633 (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) and 22634 (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; each additional interspace and segment [List separately in addition to code for primary procedure]). "These codes, new for 2012, describe the work of a combined posterolateral and posterior interbody lumbar fusion. While the scenario additionally describes discectomy and facetectomy at these levels, both are considered bundled services," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Modifier alert: The operative note must describe the additional decompression above and beyond that required to perform the interbody fusion in order to separately report the decompression with the 59 (Distinct procedural service...) modifier using code 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar) for L4-5 and code 63048 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]) for L5-S1. "The documentation provided here is not sufficient to allow separate reporting of these codes," says Przybylski.

Step 2: Code the Instrumentation and Grafts

The segmental pedicle screw instrumentation from L4-S1 would be reported as 22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure]). The interbody allograft would be reported with 20931 (Allograft, structural, for spine surgery only [List separately in addition to code for primary procedure]). Since two separate allografts are sized and placed at two separate sites, two units may be reported.

The placement of demineralized bone matrix would be reported with 20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only [List separately in addition to code for primary procedure]) and the local autograft would be reported with 20936 (Autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinous process, or laminar fragments] obtained from same incision [List separately in addition to code for primary procedure]). "Although both of these have no physician work units assigned, some payers may allow payment for these codes, and therefore it is recommended that these are reported," says Przybylski. "The intraoperative monitoring would not be separately reportable by the operating surgeon or assistant surgeon. The 3D intraoperative fluoroscopic imaging would not be separately reportable."