Orthopedic Coding Alert

Master terminology and modifier use to ensure accurate reimbursement

If you're bewildered by spinal instrumentation mysteries, take heart: Simplify your instrumentation claims by knowing whether the procedure is anterior or posterior, segmental or nonsegmental, and when to apply a modifier.
 
Our experts offer the following four tips to help you improve your instrumentation coding. 1. Select Instrumentation Codes by Type, Location When selecting among the spinal instrumentation codes (22840-22855), you should first determine the type of device the physician placed, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb. The two most common types of instrumentation are:

anterior instrumentation (22845-22847), which attaches to the front portion of the spine or vertebral segment (in other words, toward the "center" of the body)

  posterior instrumentation (22840, 22842-22844), which attaches to the back of the spine or the vertebral segment. Guidance: Generally, the instrumentation type corresponds to the surgical approach (anterior or posterior). The surgeon's documentation should explicitly state the type of instrumentation he places. If the surgeon's operative report does not specify, be sure to ask.

If the surgeon places posterior instrumentation, you must further determine if the device is segmental (22842-22844) or nonsegmental (22840).

The surest way to do this is to count the number of fixation points, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. If the surgeon attaches the instrumentation to the spine at only two points, the device is nonsegmental (regardless of the number of vertebrae spanned). If the surgeon attaches the device to at least three points (on three different segments) the instrumentation is segmental.

In some cases, the surgeon will place a metal cage or other prosthetic device for stabilization in an area where he removed a large portion of the vertebra. This represents a third type of instrumentation, which you should report using 22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace). Report only a single unit of 22851, regardless of how many devices the surgeon places at one level, Sandham says. But if the surgeon places devices on multiple spinal levels, you may report multiple units of 22851 (one unit for each individual spinal level).

Example: The surgeon places two cages at level T6-T7. Report one unit of 22851. Alternatively, the surgeon places two cages at level T5-T6 and two cages at level T6-7. Report 22851 x 2. Some payers may require you to append modifier -59 (Distinct procedural service) to the "additional" unit to demonstrate that the physician performed it at a separate anatomic location(s). 2. Count Levels [...]