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Anterior or posterior? Your coding depends on the answer.

Patients who report to the neurosurgeon for vertebral excision present an array of coding options.

Why? Vertebral excision codes encompass the surgical removal of spinal structures, from posterior elements like lamina and facet to partial vertebral body excisions. The appropriate code depends on both the vertebral segment (cervical, thoracic, lumbar) and the surgical approach.

To avoid any confusion at coding time, check out these tips on coding for vertebral excision procedures.

Decision for Surgery Comes From Imaging, E/M

Physicians decide on a vertebral excision (such as a vertebral column resection) when patients have severe, rigid spinal deformities (for example, severe scoliosis or kyphosis), spinal tumors, or infections that cannot be managed conservatively. This major procedure is considered when imaging, such as MRI or CT scans, correlates with neurological deficits or significant spinal instability. 

Over the course of several office evaluation and management (E/M) visits, a provider will assess the severity of the chief complaint to determine the course of treatment. You’ll report these E/M visits using codes from the 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 total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) set.

After approximately three months of failed conservative treatment, such as physical therapy, medication, and injections, surgery is considered. Severe deformities or unstable conditions that do not improve with less invasive methods frequently require surgery. Severe nerve compression causing weakness or bladder/bowel issues demands urgent evaluation. Malignant tumors or serious infections destroying vertebrae may also require removal for spinal stabilization. Surgeons review MRIs or CT scans to ensure anatomical problems, like severe stenosis or fractures, align with symptoms.

The final decision is a shared process that balances the severity of the symptoms, the potential benefits of surgery, and the patient’s overall health.

Know Procedure Codes for Excision Encounters 

There is a specific set of codes you’ll look to for vertebral excision procedures. Here’s a look at the code set in detail:

• 22100 (Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical)
• 22101 (… thoracic)
• 22102 (… lumbar)
• +22103 (… each additional segment (List separately in addition to code for primary procedure)).
• 22110 (Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical)
• 22112 (… thoracic)
• 22114: (… lumbar)
• +22116: (… each additional segment (List separately in addition to code for primary procedure))

You’ll decide the appropriate excision code based on the following elements:

• Approach: Codes are distinguished by whether the excision is posterior (from the back) or anterior (from the front), as well as the specific vertebral segment involved (cervical, thoracic, lumbar).
• Purpose: The surgeon typically performs these procedures to remove lesions or for decompression.
• Add-on codes: Codes +22103 and +22116 are add-on codes for additional segments.

You’ll notice that the two base codes in this set are 22100 and 22110. The primary difference between 22100 and 22110 is the specific part of the cervical vertebra being excised and the surgical approach used to access it. Code 22100 refers to the partial removal of the posterior vertebral component (for example, spinous process, lamina, or facet) in the neck. Code 22110 refers to the partial removal of the vertebral body (the anterior, main block of the bone) in the neck, typically performed without decompressing the nerves.

Mind Documentation Requirements on Your Claim

Documentation for vertebral excisions must prove medical necessity by detailing the specific spinal segment(s) involved, the exact tissue or lesion removed, the surgical approach, and the instruments used. Detailed operative reports should include preoperative imaging (MRI/CT), failed conservative treatment history, and any necessary imaging guidance (for example, fluoroscopy). 

Here’s a look at key documentation requirements for vertebral excision claims:

• Medical necessity: Explicit documentation of the diagnosis (for example, tumor, fracture, deformity) and failure of conservative treatment(s)
• Procedure description: Clear description of the resection type (partial or complete corpectomy, osteotomy), identifying the specific vertebra, and whether it was extradural or intradural
• Surgical details: Documentation of the surgical approach (for example, anterior, posterior, transperitoneal), instruments used, and all spinal segments involved
• Imaging and measurements: Preoperative imaging reports and, if applicable, measurements of the resection (for example, for osteotomies)
• Associated procedures: Detailed notes on associated procedures like instrumentation/fixation, bone grafts, or decompression
• For vertebral augmentation (if applicable): Documentation of the mechanical device used to create a cavity and the injection of cement 

When documenting these surgeries, here are some common errors to avoid:

• Confusing excision/resection with decompression (laminectomy)
• Failing to list each vertebral segment for multiple-level procedures
• Omitting the specific size or depth of tissue removed in cases of excision 

Check out This Clinical Scenario

A patient presents with severe neck pain and radiculopathy due to a localized, benign bony lesion on the posterior arch of the C5 vertebra, causing narrowing of the spinal canal.

Procedure: The surgeon performs a posterior cervical laminotomy, using specialized instruments to remove the specific bony lesion (posterior part of the vertebra) to decompress the spine, without performing a full laminectomy.

Coding: Report 22100 for the removal of the bone lesion in the cervical region. The appropriate ICD-10-CM code would be D16.6 (Benign neoplasm of vertebral column).

Three of the main details in the encounter description are:

• Location of surgery: Cervical vertebrae (neck)
• Physician action: Excision of posterior element (lamina, pedicle, spinous process)
• Purpose of surgery: Treating tumors, infections, or severe stenosis 

Review Another Clinical Scenario

A patient presents with a malignancy of the cervical spine located in the anterior portion of the C4 vertebral body, causing localized pain but no neurological symptoms or cord compression. 

Procedure: The surgeon makes an anterior cervical incision, accesses the C4 vertebra, and performs a partial vertebral corpectomy (excision) to remove the tumorous bone, followed by bone grafting to stabilize the spine.

Coding: Report 22110 for the excision of the diseased vertebral body segment. The diagnosis code would be captured as C41.2 (Malignant neoplasm of vertebral column) for the malignant neoplasm noted.

This code is distinct from those involving decompression or full corpectomy.

Jessica Sullivan, CPC, COBGC, COSC, Consultant,
Pinnacle Enterprise Consulting Services (PERCS)