Orthopedic Coding Alert
Fulfill This Requirement Before You Report 63075 With ACDF
Remember to bill multiple codes when surgeon performs ACDF If your surgeon performs an extensive diskectomy with decompression (63075) during his ACDF surgery but fails to document that he performed the diskectomy to decompress the spinal cord and/or the nerve roots, you could forfeit more than $1,000 - the amount that Medicare allots for the anterior diskectomy that goes over and above what CPT 22554 already includes for the arthrodesis. When you report arthrodesis (22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2 [fusion]) and diskectomy (63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) during the same operative session, you must indicate that the surgeon performed diskectomy to decompress the spinal cord and/or the nerve roots. Turn to 22585 and 63076 for Additional Levels If the orthopedic surgeon performs fusion and/or diskectomy at more than one interspace, you should account for the additional level by reporting add-on codes +22585 (Arthrodesis ...; each additional interspace [list separately in addition to code for primary procedure]) and +63076 (Diskectomy ...; cervical, each additional interspace [list separately in addition to code for primary procedure]) as appropriate. Report Bone Grafts Separately You should report bone grafts independently of arthrodesis. Neither CPT nor CMS bundles arthrodesis and bone graft. Generally, surgeons will place one of two types of bone grafts during ACDF: You should choose 20931 (allograft) if the surgeon uses bone taken from a bone bank or cadaver. Select 20938 (autograft) if the surgeon uses bone that he harvested from the patient's own body, Kim says.
To collect for your orthopedic surgeon's anterior cervical diskectomy with fusion (ACDF), make sure the documentation distinguishes between a minimal diskectomy to prepare the interspace for fusion, and diskectomy with decompression as required for ACDF.
Identify ACDF: ACDF consists of three basic steps, says Kee D. Kim, MD, associate professor at the University of California, Davis in Sacramento.
1. The surgeon approaches the cervical spine through an incision in the front of the neck to remove disks and/or bone spurs that may be compressing the spinal cord and/or nerve root (diskectomy with decompression). The orthopedic surgeon typically removes bone from around the area of the excised disk and then,
2. places bone grafts to stabilize the spine,
3. fuses the adjacent vertebrae, often also using titanium plating (instrumentation), and may insert caging.
If You Claim Diskectomy, Document the Reason
Insurers often reduce or deny claims for 63075 during ACDF because the descriptor for 22554 specifically includes minimal diskectomy to prepare the interspace. Therefore, your documentation must clearly support 63075 by describing the orthopedist's decompression of the neural elements and removal of 1) any fibrovascular scar tissue over the dura, 2) any disk material on the far lateral sides, and 3) any osteophytes (bone spurs) that may be present.
Appeal if you have to: If your insurer denies a properly documented diskectomy with decompression (63075) and fusion (22554), be sure to contact the payer and explain that the services are distinct and deserve separate payment. Many carriers have set up computer edits to catch and reject certain coding combinations. These edits cannot determine the extent of the services the surgeon provided, and, consequently, some legitimate claims (including many ACDF claims) are rejected.
Example: The surgeon performs diskectomy with nerve decompression and removal of bone spurs at interspaces C3/C4 and C4/C5, followed by fusion at both levels. You would report 63075 for diskectomy at the initial interspace and 63076 for the second interspace. Likewise, you should claim 22554 for fusion at the first level and 22585 for fusion at the subsequent level.
Tip: Don't bill separately for the operating microscope. Surgeons often use an operating microscope during diskectomy with decompression, Kim says. You should not, however, report +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) in addition to 63075/63076. CPT defines use of the operating microscope as an inclusive component of diskectomy.
Don't overcode: You should report only one code unit per type of bone graft, "regardless of the number of vertebral levels being surgically fused (i.e., not once per spinal interspace or segment fused)," according to the January 2004 CPT Assistant.
Example: During the same surgery described in the previous example, the surgeon places grafts taken from the bone bank at the C3/C4 and C4/C5 interspaces. In addition to reporting the diskectomy and arthrodesis codes (as above), you should claim 20931 to describe placement of the allografts. Although the surgeon placed bone grafts at two levels, you should claim only a single unit of 20931, says Chris P. Galeziewski, CPC, orthopedic coder at the Kelsey-Seybold Clinic in Houston.
"Code 20931 is not bundled into the arthrodesis, but this does not preclude any erroneous commercial payer contract issues," Galeziewski says, so practices should check their contracts to ensure that their insurers don't automatically bundle the grafting into the surgical codes.
Remember instrumentation: Bill for anterior instrumentation, if the surgeon places it, by using 22845 (Anterior instrumentation; 2 to 3 vertebral segments) or 22846 (... 4 to 7 vertebral segments).
If your surgeon uses cages, you should also report 22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace). According to the January 2001 CPT Assistant, "If the surgeon uses a threaded bone dowel or prosthetic device in the disk space, then code 22851 should be reported. If any other type of bone graft is performed, the appropriate bone graft code should be reported."
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