Orthopedic Coding Alert

3 key factors you'll need to identify to avoid denials.

When your orthopedic surgeon performs spinal osteotomies, you'll stand a much better chance of achieving full deserved reimbursement if the procedure note clearly defines the surgeon's intent and approach. Specifically, look carefully for whether the physician performed decompression beyond the osteotomy and scrutinize the operative note for indications that a discectomy has been performed.

Spinal osteotomy is performed when fusion alone would not correct a spinal deformity like a change in anterior or lateral curvature of the spine. "Osteotomies are only indicated when a corrective fusion is not enough. If the degree of deformity is severe, then and only then is an osteotomy indicated," explains Jennifer Schmutz, CPC, health information coder at the Neurosurgical Associates, LLC in Salt Lake City, Utah.

Report spinal osteotomy when the operating surgeon removes a portion of the vertebral segment(s) using codes in the 22206 to 22226 range.

Key: Accurate code selection depends on three factors: (1) the approach, (2) the anatomical location of the  procedure in the spine, and (3) the number of vertebral segments operated upon. Keep in mind that location refers to the area of the spine which is being worked on, which can be cervical (C1-C7), thoracic (T1-T12), lumbar (L1-L5) or sacral (S1-S4).

1. Identify the Approach

Read through the notes to identify the patient's position, supine or prone, to get started. When physicians add information about the approach to the operative report, this "helps the coder to select the correct code to be billed," affirms Teresa Thomas, BBA, RHIT, CPC, practice manager II at St. John's Clinic (Neurosurgery) in Springfield, Missouri.

Report code 22206 (Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (e.g., pedicle/vertebral body subtraction); thoracic), 22207 (Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (e.g., pedicle/vertebral body subtraction); lumbar) or 22208 (Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/ vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure)) when the neurosurgeon uses a posterior or posterolateral approach for pedicle subtraction osteotomy (PSO), three column closing wedge posterior osteotomy, and vertebral column resection (VCR). "These codes are to be used for osteotomies that remove a V-shaped wedge from the vertebral body, at least two-thirds, as well as all of the posterior elements -- pedicles, articulating facets, lamina and spinous process," explains Schmutz.

Depending upon location, you would report code 22210 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical), 22212 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic), or 22214 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar) for posterior approach in the cervical, thoracic, and lumbar regions, respectively for Ponte osteotomy, posterior closing wedge osteotomy (with or without opening of the anterior column), Smith-Peterson osteotomy, and polysegmental  osteotomy. "These codes describe osteotomies that remove part or all of the posterior elements but do not remove the vertebral body," elaborates Schmutz.

Similarly, if the approach is an anterior one for osteotomy and discectomy and the procedure involves a single vertebral segment, you would assign codes 22220 (Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical) for the cervical region, 22222 (Osteotomy of spine, includingdiscectomy, anterior approach, single vertebral segment; thoracic) for the thoracic region and 22224 (Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar) for the lumbar region.

2. Build in Add-ons for Multiple Levels

For every additional vertebral segment in the posterior or posterolateral approach after the first segment operated upon, report code 22216 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure)) in addition to the primary procedure code.

"The CPT book lists the add-on code under each primary approach code for each additional vertebral segment that would need to be billed," says Thomas. "For example, for primary code 22210 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical) for cervical osteotomy of spine posterior approach, 1 vertebral segment, the add-on code for additional vertebral segment would be 22216," offers Thomas. "Osteotomy procedures are coded per vertebral level. If the posterior elements were removed from T10, T11 and T12 as in the Ponte or Smith-Peterson osteotomies, you would report 22212 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic) for T10, 22216 x2 for T11 and T12," supports Schmutz.

Example: An operative note may indicate "L1 and L4 Smith Peterson osteotomy was performed." In this case, you would report 22216 as an additional code to 22214 which describes the lumbar location of the osteotomy. Similarly, for each additional vertebral segment in an anterior approach, you would list 22226 (Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)) in addition to the code for the primary procedure.

3. Don't Separately Report Decompression

Decompression of the spinal cord, cauda equina, and/or single or multiple nerve roots is implied in osteotomies and the codes for osteotomies are inclusive of these. "Decompression is essentially inherent to an osteotomy," confirms Schmutz. "Osteotomy procedures entail removing a piece of the vertebrae to correct spinal alignment; these codes replace laminectomy, laminotomy, and discectomy procedures and should not be reported at the same levels," she explains further.

The levels of decompression need to be clearly defined in all operative notes. "Without this documentation, you would not be able to bill for the decompression separately from the osteotomy," specifies Thomas. To assign the correct number for every root being decompressed, you should keep an eye on details for every level to avoid any overlap or to miss reporting a procedure.

Choose codes 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar) and 63048 (...each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]) for decompressions that are separate and distinct in anatomical locations from the osteotomy.

Example: If the operative note states, "bilateral pars osteotomies at the L4 level and a laminectomy at the L4-5 interspace," then the osteotomy and the decompression have a common level. The code in this situation may be either 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar) or 22214 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar), but not both. However, decompression for L4-S1 needs independent coding with 63047-59 to describe the laminectomy at the L5-S1 interspace, assuming that a laminectomy with at least partial  facetectomy has been performed. Here, the modifier 59 (Distinct procedural service.......) implies the distinct procedure of decompression at an additional level.