Neurosurgery Coding Alert

Further, there are several services represented with add-on codes that you might need to add to your claim in order to max out your practice’s rightful reimbursement.

Check out this how-to on coding for patients who need cervical arthrodesis below C2.

Look for Presurgical E/M, Imaging

In addition to an office/outpatient evaluation and management (E/M) service to address a patient’s cervical issues, the surgeon will likely order some type of imaging test (or tests) to confirm that the patient needs cervical arthrodesis.

When the surgeon performs cervical imaging for potential arthrodesis candidates, you’ll likely see one or two of these codes:

• 72020 (Radiologic examination, spine, single view, specify level)
• 72040 (Radiologic examination, spine, cervical; 2 or 3 views)
• 72050 (… 4 or 5 views)
• 72052 (… 6 or more views)
• 72081 (Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view)
• 72082 (… 2 or 3 views)
• 72083 (… 4 or 5 views)
• 72084 (… minimum of 6 views)
• 72125 (Computed tomography, cervical spine; without contrast material)
• 72126 (… with contrast material)
• 72127 (… without contrast material, followed by contrast material(s) and further sections)

Example: A new patient reports to the neurosurgeon with pain in their neck and upper back radiating to the right arm. After an office E/M that includes moderate-level medical decision making (MDM), the surgeon orders a three-view cervical spine X-ray, as well as a computed tomography (CT) without contrast material. The surgeon then diagnoses the patient with cervical spondylosis at C6-C7.

For this encounter, you’d 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
• 72082 for the X-ray
• 72125 for the CT study
• M47.23 (Other spondylosis with radiculopathy, cervicothoracic region) appended to 99204, 72082, and 72125 for to represent the patient’s osteophyte compressing the C7 nerve

Use This Code Combo for Arthrodesis

When the surgeon decides to perform a single-interspace arthrodesis, you’ll report it with 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2).

Remember to report a code for each interspace the surgeon treats with arthrodesis; if multiple levels are treated, report each additional level beyond the first with +22552 (… cervical below C2, each additional interspace (List separately in addition to code for primary procedure)). Also, remember to look for other codeable procedures — likely in the form of add-on codes — that you might report with the arthrodesis.

“In all levels, report additional add-ons for grafts and instrumentation if used,” explains Jessica Miller, MHA, CPC, VP revenue cycle for Ortmann Healthcare Consulting Services. Examples of add-ons you might include with 22551/+22552 include:

• +22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure))
• +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure))
• +20931 (Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure))
• +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))
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)).