Orthopedic Coding Alert

Approach, span and devices influence your claim

If your surgeon provides spinal instrumentation services, you'll need to identify what instruments were used and whether the physician removed and reinserted the instrumentation. Brush up on your spinal instrumentation coding skills -- and improve your claim results for these services by following some important tips.

Look for Device Your Surgeon Places

When your surgeon places wires, screws, rods, or any other instruments, you can efficiently select the appropriate code if you know the approach and fixation points.

There are ten codes you can choose from when you report spinal instrumentation:

• 22840 -- Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxialtransarticular screw fixation, sublaminar wiring at C1, facet screw fixation)[List separately in addition to the code for primary procedure]
• 22841 -- Internal spinal fixation by wiring of spinous processes [List separately in addition to the code for primary procedure]
• 22842 -- Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminal wires); 3 to 6 vertebral segments [List separately in addition to the code for primary procedure]
• 22843 -- Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminal wires); 7 to 12 vertebral segments [List separately in addition to the code for primary procedure]
• 22844 -- Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminal wires); 13 or more vertebral segments [List separately in addition to the code for primary procedure]
• 22845 -- Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to the code for primary procedure]
• 22846 -- Anterior instrumentation; 4 to 7 vertebral segments [List separately in addition to the code for primary procedure]
• 22847 -- Anterior instrumentation; 8 or more vertebral segments [ List separately in addition to the code for primary procedure]
• 22848 -- Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum [List separately in addition to the code for primary procedure]
• 22851 -- Application of intervertebral biomechanical device(s) (e.g., synthetic cage[s], threaded bone dowel[s], methylmethacrylate) to vertebral defect or interspace. [List separately in addition to the code for primary procedure]

Determine the Approach

The first step to select the right code is to determine whether the orthopedic surgeon adopted an anterior or posterior approach for the instrumentation. You will usually be able to catch the clue in the operative note when you read through carefully. You select from codes 22840, 22842, 22843, and 22844 for a posterior approach and 22845, 22846, and 22847 for an anterior approach for the spinal instrumentation. "Documenting the approach (anterior, posterior, direct lateral, extreme lateral) is something that spine surgeons do almost unfailingly," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

Count Fixation Points in Posterior Approach

Once you confirm the posterior approach, the next step is to determine if the device is segmental (22842-22844) or nonsegmental (22840). For this portion, you count the fixation points.

Irrespective of the span, if the instrumentation is done to only two vertebral segments, you consider the instrumentation to be non-segmental and report code 22840. If, however, the instrumentation involves three or more vertebral segments, the instrumentation is considered segmental.

"In order for instrumentation to be considered segmental, there must be a proximal fixation point and a distal fixation point with at least one intervening fixation point," confirms Stout. "A pedicle screw construct that runs from L2 to S1 with screws placed at all intervening levels constitutes 5 segment instrumentation and is reported with code 22842. On the other hand, if a rod and screw construct spans L2 to S1 but no screws are placed at any intervening level, this is non-segmental fixation and is reported with code 22840," she adds. .

Confirm Removal of Vertebral Portions

Your surgeon may remove a portion of the vertebra and may have used a metal cage or other prosthetic device to stabilize the area. You specifically report this as code 22851.

Remember: When reporting 22851, you count the spinal units and not the instruments. If the surgeon uses multiple devices at one level, you report only a single unit of 22851. If, however, the surgeon places devices at more than one spinal level, you report one unit of 22851 for each individual spinal level.

Example: If your surgeon places two cages at T4-T5, you report one unit of 22851. However, if your surgeon places one cage at T3-T4 and two cages at level T5-T6, you report 22851 x 2.

Distinguish Instrumentation Removal

There are different codes you choose from when your surgeon is removing the spinal instrumentation. You can report the instrumentation removal if the surgeon removes the instrumentation for damage or rejection. You can also report the instrumentation removal if your surgeon did it to adjust the instrumentation. If, however, the surgeon does the removal to explore the spinal fusion, you cannot report the instrumentation removal.

You select from the following codes when reporting the instrumentation removal:

• 22850 -- Removal of posterior nonsegmental instrumentation (e.g., Harrington rod)
• 22852 -- Removal of posterior segmental instrumentation
• 22855 -- Removal of anterior instrumentation.

Report Reinsertions

Your surgeon in some instances like a repeat fusion may reinsert the instrumentation after the procedure is complete; in this case, you would report 22849 (Reinsertion of spinal fixation device).

Be Careful with Modifiers

Confirm with your payer which modifiers are approved for spinal instrumentation services, as not all may be accepted.. Some will permit modifier -59 (Distinct procedural service) to the 'additional' unit(s) to demonstrate that the surgeon did the instrumentation at separate anatomic location(s).

Example: If your surgeon places one cage at T3-T4 and two cages at level T5-T6, you report 22851 x 2 and append modifier -59 depending upon your payer. "In this scenario, CPT® advises reporting the cages placed at different spinal interspaces as two line items, 22851 and 22851-59," says Stout.

Spinal instrumentation codes (22840-22848 and 22851) are modifier -51 (Multiple procedures) exempt, so you would not report -51 with any of these. Carefully study the operative note to determine where the surgeon places the instrumentation

Example: If you read that the surgeon performed arthrodesis at interspaces C6-7, C7-T1 and T1-2 and placed anterior instrumentation attached at C6 and T2, you report 22846 for the instrumentation, one for the segments C6 to T2. You also report the appropriate codes for arthrodesis. These are 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2), 22556-51 (... thoracic) and +22585 (... each additional interspace [list separately in addition to code for primary procedure]). "When an arthrodesis crosses spinal regions (in this case from cervical to thoracic), only one primary arthrodesis code can be reported. In this case, you would report 22556 and +22585, +22585-59. Also report the code for the type of interbody device and/or graft material that was used. If a separate anterior plate is applied from C6 to T2, report code 22846," says Stout.

When your surgeon is removing the instrumentation in the global period and an infection necessitated the return of the patient to the operating room for the removal, you append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the appropriate spinal instrumentation removal code. "Codes for spinal instrumentation removal are 22855, 22850, and 22852," says Stout.