Orthopedic Coding Alert

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 and Interspaces Carefully

CPT defines codes for segmental and nonsegmental (both anterior and posterior) instrumentation according to the number of vertebral segments involved (for example, the descriptor for 22842 specifies "... 3 to 6 vertebral segments"), so you must count your vertebrae carefully.

Remember: There are seven cervical vertebrae, 12 thoracic vertebrae and five lumbar vertebrae (plus the sacrum).

Although CPT defines instrumentation procedures according to vertebral segments, it defines fusion (arthrodesis) procedures (which must accompany instrumentation claims) according to vertebral interspaces, so you must be careful to avoid confusion. For example, the span T12-L4 contains five vertebral segments (T12, L1, L2, L3, L4) but only four vertebral interspaces (T12/L1, L1/L2, L2/L3, L3/L4).

Example: The surgeon performs arthrodesis from C6 to T2. He places anterior instrumentation attached at C6 and T2. In this case, report 22556 (Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; thoracic) and  +22585 x 2 (... each additional interspace [list separately in addition to code for primary procedure]) for the arthrodesis and 22846 (Anterior instrumentation; 4 to 7 vertebral segments) for the instrumentation.

3. Don't Apply Modifiers for Initial Surgery

You should not append modifiers -50 (Bilateral procedure), -51 (Multiple procedures) or -59 (Distinct procedural service) to the instrumentation codes (except to denote different levels for cage placement, as discussed above).

CPT defines instrumentation procedures as inherently bilateral, so you should never use modifier -50, Bucknam says.

And, although not "add-on" procedures, all codes describing instrumentation placement (22840-22848, 22851) are exempt from multiple-procedure (modifier -51) adjustments, according to CPT. Because a surgeon would never report instrumentation alone (at a minimum, he would also perform arthrodesis), the value assigned to these codes already takes into account their status as "additional" but independent procedures.

For the same reasons, you shouldn't append modifier  -59 to instrumentation codes that you report with other spinal procedures.

4. Do Apply Modifiers for Follow-up Surgery

When reporting follow-up procedures for instrumentation during the 90-day global period of an initial surgery, you may need to use modifiers, Sandham says. To make modifier use easy, follow these guidelines and examples: