Neurosurgery Coding Alert
Get Segment Count Before Coding Arthrodesis
Question: Encounter notes indicate that on Monday, the surgeon provided a level-four evaluation and management (E/M) service for a new patient with diagnosis of cervicothoracic postural kyphosis. On Tuesday, the surgeon performed anterior arthrodesis for spinal deformity. The notes do not indicate whether casting was used. How can I choose the correct CPT® code if I don’t know this information? Tennessee Subscriber Answer: You don’t need to know whether casting was used, as the CPT® codes for this procedure all read “with or without cast.” You will, however, need to know how many vertebral segments your surgeon treated. Do this: Go back and check the encounter notes for evidence of a vertebral segment count. Then, report: 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) for the E/M 
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Get Segment Count Before Coding Arthrodesis
Question: Encounter notes indicate that on Monday, the surgeon provided a level-four evaluation and management (E/M) [...]
