Here’s How to Confidently Navigate Coding Arthrodesis for Spinal Deformity
Did you know that spinal deformity arthrodesis follows a different set of coding rules than routine spinal fusion? Spinal deformity surgery creates distinct coding challenges because these procedures focus on correcting abnormal spinal alignment rather than treating routine degenerative conditions. The CPT® code range 22800-22812 (Posterior/Anterior spinal fusion for deformity …) describes arthrodesis performed for deformity correction, and it follows different rules than standard spinal fusion codes. To report these services correctly, coders must recognize when a procedure qualifies as deformity surgery and understand how the documented surgical approach drives code selection. Because deformity arthrodesis follows different clinical and coding rules than routine spinal fusion, even small documentation details can affect code selection. Read on to learn how providers evaluate, treat, and document spinal deformities so you can avoid common coding errors in spinal deformity surgery. Know the ICD-10-CM Codes For Spinal Deformities Treated With Arthrodesis Physicians perform deformity arthrodesis to restore normal alignment when spinal curvature or a rotational deformity interferes with overall function. These conditions typically involve more than simple instability or degeneration, and they may cause issues with posture or balance. Code sets for common conditions managed with arthrodesis include: M41.- (Scoliosis) and M40.0- (Kyphosis and lordosis). Coders should also recognize Q67.5 (Congenital deformity of spine) and Q67.4- (Other congenital malformations of spine). Keep in mind that CPT® codes 22800-22812 do not apply to fusions performed solely for degenerative disc disease, stenosis, or spondylolisthesis; therefore, it’s critical to verify that there is a deformity diagnosis that requires surgical correction in the patient’s medical record. Understand the Physician’s Decision-Making Process Physicians base the decision for deformity correction surgery on clinical evaluation and the results of imaging tests such as a standing full-spine radiograph, an MRI to evaluate neural compression, or a CT scan that assesses vertebral anatomy and rotational deformity. During the clinical evaluation, the provider will take a comprehensive history and assess the patient’s pain severity, functional limitations, neurologic deficits, and spinal curvature. Depending on the severity of the deformity, the provider may also assess the deformity’s effects on the patient’s pulmonary or cardiovascular function. If a separate evaluation/management (E/M) service occurs on the day of surgery decision-making, use the appropriate E/M code and apply modifier 57 (Decision for surgery). Remember that modifier 57 is reserved for major procedures; use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure) when a separate E/M service occurs on the same day as surgery decision-making for a minor procedure. Learn the Differences Between Anterior/Posterior Approaches The surgeon’s approach directly affects which CPT® code is the correct choice. In an anterior approach, the surgeon accesses the spine from the front or side of the body, through the thoracic or abdominal cavity. The surgeon removes intervertebral discs and places bone graft material to fuse the vertebral bodies. This approach allows direct access to the vertebrae and usually uses fewer fusion levels than the posterior approach, where the surgeon accesses the spine through the back. The posterior approach is common in long-segment deformity corrections, and it enables the placement of rods, screws, hooks, and wires. It allows for direct decompression of neural elements and supports multi-planar correction. Before you select a code from the 22800-22812 range, confirm the surgical approach in the documentation. Master the 22800–22812 CPT® Code Range These codes describe primary deformity correction fusions and differ from standard arthrodesis codes, which have their own code sets. The 22800-22812 code set includes: Avoid reporting standard fusion codes with these procedures unless documentation supports a separate, distinct fusion in another spinal region. Deformity correction almost always involves spinal instrumentation, which coders must report separately unless bundled. Instrumentation codes include: Review This Deformity Surgery Example Michelle Falci, BA, M Falci Communications LLC
Include Instrumentation Coding for Deformity Surgery
Let’s examine an example of a patient whose surgery involved an anterior approach. Say that a 17-year-old patient presents with progressive idiopathic thoracolumbar scoliosis measuring 55 degrees despite bracing. Imaging confirms a structural curvature with vertebral rotation, prompting surgical intervention. The surgeon performs an anterior thoracolumbar spinal fusion from T10 through L2, removes the intervertebral discs, places a structural bone graft, and applies anterior instrumentation to correct the deformity.
In this case, the documentation supports reporting 22810 for anterior spinal fusion for deformity in the thoracolumbar region, along with +22846 for anterior instrumentation. If the documentation supports it, the surgeon may also report an appropriate bone graft code, such as +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)). Remember to append M41.125 (Adolescent idiopathic scoliosis, thoracolumbar region) to 22810, +22846, and +20936 (if reported) to represent the patient’s scoliosis.
