Neurosurgery Coding Alert

Question: My neurosurgeon performed a PLIF with a discectomy. He used a structural iliac crest autograft for fusion at L4/L5 and L5/S1 interspaces. Which CPT^® codes should I report for this case?

Georgia Subscriber

Answer: You should report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar) for the L4/L5 interspace and +22632 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)) for the additional L5/S1 interspace. The structural iliac crest autograft would be correctly reported once with +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)), despite placement of two interspace grafts.

Don’t miss: If the surgeon performed a combined posterolateral and posterior interbody fusion, you should report 22633 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar) and +22634 (… each additional interspace and segment (List separately in addition to code for primary procedure)) instead of 22630 and +22632.

If only a posterolateral fusion is performed at L5S1, then you should report +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)) for the additional L5/S1 posterolateral fusion, instead of +22632 for an additional level posterior interbody fusion.