Neurosurgery Coding Alert

Report multiple grafts but modifier -51 does not apply.

Coding for spinal bone grafting may leave you perplexed as these procedures involve determining which graft type your neurosurgeon used, identifying any accompanying procedures, and reporting multiple grafts. Read on for advice on how to finesse your spinal graft claims and beat denials.

Use 3 Aspects to Guide Your Graft Code Selection

When reporting spinal bone grafts, you'll choose from the five codes listed below:

• +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)
• +20931 (Allograft, structural, for spine surgery only [List separately in addition to code for primary procedure])
• +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])
• +20937 (Autograft for spine surgery only [includes harvesting the graft]; morselized [through separate skin or fascial incision] [List separately in addition to code for primary procedure])
• +20938 (Autograft for spine surgery only [includes harvesting the graft]; structural, bicortical or tricortical [through separate skin or fascial incision] [List separately in addition to code for primary procedure])

Use this 3-step formula to narrow down to the right code for spinal bone grafting.

1. Confirm the source of the graft. Your surgeon may use an allograft or an autograft. Review the operative note to determine if the bone used for grafting was obtained from the patient's own body (autograft) or was obtained from a donor (allograft). For example, the surgeon may use a rib or iliac crest to complete a spinal fusion. In this case, you look for a bone graft code describing an autograft.

2. If the graft's an autograft, confirm how the surgeon obtained the bone for grafting. Your surgeon may approach the bone through the same incision (local) or may make a new incision at another site in the skin and/or fascia to obtain the graft.

3. Lastly, you confirm if a single "structural" piece of bone or multiple small pieces were used for grafting. If your surgeon used a single bone as a graft, you select a 'structural' bone graft (+20931 and +20938). If, however, your surgeon uses multiple small fragments of bone to promote new bone growth and fill up a cavity in the spine, you select one of the codes for morselized grafts (+20930 and +20937).

Report Grafts with Arthrodesis and Spinal Instrumentation

You individually report codes for bone grafts unless the code descriptor includes grafting as a procedure. "The bone graft codes are not bundled into either the arthrodesis or instrumentation codes," says Jennifer Schmutz, CPC, health information coder at the Neurosurgical Associates, LLC in Salt Lake City, Utah.

Exception: Medicare does not assign payment for the spinal graft codes 20930 and 20936, as these are bundled into codes for other services or do not incur physician work. Zero relative value units are assigned to these codes in the national Physician Fee Schedule Database.

Appeal Denials for Grafts with Arthrodesis

If your payer denies a separate payment for bone graft codes (+20930-+20938) when reported with arthrodesis, you should appeal the claim.

Hint: You can support the claim with specific instructions from CPT which directs that codes for autogenous bone grafts should be reported separately unless the code descriptor references the harvesting of the graft.

"Even though 20930 and 20936 have no assigned relative value units, you should still have a fee schedule for both. While CMS will not pay for these codes, you should still report them when performed as private payers may pay for them," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Modifier -51 Does Not Apply

You should not append modifier -51 (Multiple procedures:...) to +20930-+20938. Spinal bone grafts are add-on procedures associated with a definitive spine surgery. When reporting them with the definitive spine surgery code, you should never use modifier -51. "Bone graft codes are modifier -51 exempt because they are add-on codes and need to be reported with the arthrodesis codes," says Schmutz.

Capture Multiple Graft Services

When performing arthrodesis procedures at multiple levels, your surgeon may use more than one graft. You will need to confirm with your payer for reporting multiple grafts. Generally, each type of bone graft may be reported typically one time regardless of the number of segments being fused.

You do not report one graft per segment or level. "The bone grafts codes can be reported once per session for each type of bone graft used," says Schmutz. In an exceptional situation, your surgeon may use both an autograft and an allograft at different levels. In this case, you can report multiple bone graft codes.

"Another exception occurs when the same graft type is harvested from a completely separate body site. For example, in anterior and posterior surgery, you may report the harvest of a cancellous autograft (+20937) from an anterior iliac site and a posterior iliac site," says Przybylski. "The -59 (Distinct procedural service:...) modifier should be applied to identify the separate surgical site. However, a payer may have a payment policy that will not recognize the additional physician work. In contrast, one would not report +20937 cancellous iliac autograft and +20938 structural iliac autograft from the same single surgical site."