Orthopedic Coding Alert

Question: My orthopedist performed an arthrodesis, discectomy and osteophytectomy, removing about four or five disc fragments from the left neural foramina. He then placed a Synthes plate with two screws at C7 and two screws at T1. How should I code this procedure?

Florida Subscriber

Answer: Assuming your surgeon performed this procedure anteriorly, you-ll report three codes to represent your orthopedist's work:

- 63075 -- Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace

- 22554 -- Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 for the arthrodesis 

- 22845 -- Anterior instrumentation; 2 to 3 vertebral segments.

The Correct Coding Initiative (CCI) does not bundle any of these codes, so you should not need to append modifiers to any of the codes. But your payers may have different rules, so you should check with them to determine how their rules might affect your coding.

You-ll also report a graft code (20938, Autograft for spine surgery only [includes harvesting the graft]; structural, bicortical or tricortical [through separate skin or fascial incision]; or 20931, Allograft for spine surgery only; structural) depending on the type of graft your orthopedic surgeon uses for the interbody fusion. For the autograft, the surgeon uses the patient's own bone harvested from another part of the body, and for an allograft, the surgeon uses bone from a cadaver.