Orthopedic Coding Alert

Laura Nuechterlein, MPA, senior policy analyst for the American Academy of Orthopedic Surgeons (AAOS) reports that some orthopods have had difficulties in gaining reimbursement for performing an arthrodesis (a spinal fusion) in conjunction with a diskectomy (removal of disk). According to CPT 1999, an anterior arthrodesis (22554) allows for a minimal diskectomy in the cervical below C2 to prepare interspace other than for decompression, while an anterior diskectomy (63075) specifically encompasses decompression of the spinal cord.

Brenda Bosch, CPC, reimbursement analyst for St. Alexius Medical Center in Bismark, ND, is a 22-year coding veteran who says understanding the full definition of each code is critical. Theres very little risk when performing a minimal diskectomy because youre not touching the spinal cord, youre just clearing the space. But if youre going in and actually removing that disk, theres a very high level of risk because youre on the spinal cord, youre decompressing, so thats an entire procedure in and of itself.

You may have physicians who say, Every time I touch a disk, Im going to use both codes, and thats inappropriate. Then you have the physician who looks at 22554 and says, This includes a diskectomy, so I can never bill separately for that procedure. That, too, is inappropriate.

Sowhen should you bill for both codes? That depends on why youre operating in the first place.

Arthrodesis is Required Because of Findings During Diskectomy

If your patient is suffering from a compression of the spinal cord (336.9 or 952.xx) due to a dislocated disk (839.xx) and it is necessary to remove that disk in order to alleviate the complaint, an instability of the spine (724) may then occur or be revealed. This is very common in the cervical area, says Bosch. Because of the way these bones are shaped, youre not always going to have stability after removing a disk.

At this stage, a separate, secondary procedure must be performed to address the problem. The arthrodesis fusion (27870 or 22548) is the most common. It is absolutely appropriate to bill for both procedures under these circumstances. You will probably also be billing for a bone graft (20900) and instrumentation (22840-22899).

Bosch suggests that if you are dealing with a new carrier, it will save you time in the reimbursement process to include documentation with your claim. Weve had to send in full op reports to prove that we were removing an entire disk and not just scraping away a little disk bone or jelly to get into the space, and that we were performing a decompression of the spinal cord, says Bosch, a former American Academy of Professional Coders chapter president.

She also suggests including a letter explaining the medical necessity for the arthrodesis above and beyond the diskectomy.

Arthrodesis with Minimal Diskectomy

Before surgery, the orthopod should be aware, based on the initial complaint and all subsequent examinations with MRI, CAT-scan, or angiogram, if a full diskectomy is going to be required in addition to the fusion.

The anterior arthrodesis code (22554) includes a minimal diskectomy, Bosch explains. That is when youre scraping away only part of the disk in order to clear a space for your fusion. The disk isnt causing a compression on the spine, so a full diskectomy isnt needed.

Note: In this scenario, 63075 (diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) would be an incorrect code to add to the arthrodesis procedure code.

Arthrodesis and Diskectomy Combined from the Outset

A compression may very well go along with an instability of the spine. It is common for surgeons to perform an arthrodesis and a full diskectomy at one time. Medical necessity needs to be thoroughly documented and it should be made clear when you submit your claim that these two procedures were done to address significant and distinct problems in order to get reimbursed.