Revenue Cycle Insider

Question: The surgeon performs arthrodesis via posterior technique on a patient with cervical osteomyelitis. How should I report this encounter?

Nebraska Subscriber

Answer: It depends on the particular cervical area that the surgeon treated. There are a trio of codes for arthrodesis involving the cervical portion of the spine.

Go back and check the encounter notes for more information on the location of the surgery. Then, choose one of the following codes:

• 22590 (Arthrodesis, posterior technique, craniocervical (occiput-C2)): Per Codify, the surgeon performs this type of arthrodesis “to permanently join the second cervical vertebra in the neck to the base of the cranium.”
• 22595 (Arthrodesis, posterior technique, atlas-axis (C1-C2)):  According to Codify, the surgeon performs this type of arthrodesis to “permanently join the first two vertebrae, the interlocking bones of the neck.”
• 22600 (Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment): Use this code for all posterior cervical arthrodesis procedures below C2. If the surgeon treats additional interspaces below C2, you’ll report +22614 (… each additional interspace (List separately in addition to code for primary procedure)) for each additional interspace.

Be sure to append M46.22 (Osteomyelitis of vertebra, cervical region) to the surgical code(s) you choose to represent the patient’s osteomyelitis.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC