Orthopedic Coding Alert
Understand the Building Blocks of Spinal Reconstruction Surgery Coding
When you comprehend the large number and complexity of terms associated with spinal anatomy, disorders and surgical procedures, coding for spinal reconstruction surgery becomes less daunting. Consequently, you will leave less reimbursement on the table. A coder unfamiliar with spine procedures may be baffled by an operative report that reads, laminectomy" L4-5 foraminotomies L4 L5 S1 posterolateral fusion with pedicle fixation L4-5 left iliac crest bone graft." An understanding of these terms can make the spinal coding process a surmountable challenge. Coding Spinal Reconstruction Procedures Among the most complicated of an already complex subspecialty spinal reconstruction procedures are used to correct injuries to the spine caused by external factors (falls accidents etc.) and degenerative or deformative diseases such as scoliosis or degenerative disc disease. These procedures involve the use of fusion instrumentation or cages. When and How to Report Arthrodesis Also referred to as spinal fusion arthrodesis involves removing corrupt vertebra and disk material and replacing it with bone graft or instrumentation to stabilize the spine. It is often performed in combination with other spine procedures and can be approached from the anterior posterior posterolateral or lateral transverse positions. Fusion can be required for several reasons: to treat a vertebral fracture to correct degenerative conditions or to correct deformity from scoliosis or kyphosis. Codes 22554-22558 (Arthrodesis anterior interbody technique including minimal diskectomy to prepare interspace [other than for decompression ]) are for anterior fusions or arthrodesis at the cervical level below C2 thoracic and lumbar levels and +22585 ( each additional interspace [list separately in addition to code for primary procedure]) is the add-on code for each additional interspace(s). Code 22548 (Arthrodesis anterior transoral or extraoral technique clivus-C1-C2 [atlas-axis] with or without excision of odontoid process) is different from the other anterior fusion codes in that rather than approach the surgical site through an incision in the neck or trunk the surgeon approaches orally or through the patient's mouth. Obviously this code is only for surgeries to the cervical area. Instrumentation Billing Spinal instrumentation consists of rods screws hooks cages and synthetic bone materials that are inserted into the spine to provide stability and in some cases hold the spinal column together. Instrumentation codes 22840-22848 and 22851 (Application of intervertebral biomechanical device[s] [e.g. synthetic cage(s) threaded bone dowel(s) methylmethacrylate] to vertebral defect or interspace) are always billed in conjunction with arthrodesis codes. Because the instrumentation placement involves one surgeon performing the primary procedure and another assisting these codes do not require modifier -51 (Multiple procedures) or modifier -62 (Two surgeons). Codes 22849 (Reinsertion of spinal fixation device) and 22850 (Removal of posterior nonsegmental instrumentation [e.g. Harrington rod]) are for reinsertion or removal of instrumentation and can be reported absent an arthrodesis code and are not modifier -51 exempt. Understand Coding for Pressure Relief Procedures Codes 63001-63048 describe surgeries performed to relieve pressure on neural elements or to remove herniated disks. These procedures involve excising corrupt disk material or opening new or enlarging existing holes in the laminae to facilitate release of the spinal cord. Although closely related to one another each procedure differs slightly: Facetectomy and foraminotomy are almost always performed with other spinal surgeries. Coding Case Study "The physician did a posterior spinal fusion with instrumentation from L3 to T7 " says Eileen Bradley CPC coding specialist at Brigham and Women's Hospital in Brookline Mass. Between counting the numerous levels involved and the added twist of the fusion traversing more than one region of the spine the procedure presents several coding challenges. In this case the biggest risk is undercod-ing which means lost revenue for the practice. The surgery presents two potentially "correct" coding sequences. The procedures performed are clearly delineated but the uncertainty lies with how often to record them on the claim form and in what order. But in Bradley's case the thoracic and lumbar fusions could be considered "primary." Some coders advocate listing both primary codes on the claim form and modifying one with modifier -51. In other words the fusions are always broken into distinguishable primary surgery codes e.g. the initial thoracic fusion plus added levels and the initial lumbar fusion plus added levels. Using that rationale the claim form would read as follows: The North American Spine Society publishes Common Coding Scenarios for Spine Procedures and Injection Techniques a guide that breaks down coding for the most common spine procedures and appears to resolve this debate. Based on its example when a fusion or other procedure crosses from one spinal area into another (e.g. thoracic to lumbar) coders should still pick only one code for the primary then use 22614 for all additional levels regardless of whether they are thoracic lumbar or cervical.
Codes 22548- 22899 describe reconstructive surgeries to the spine. The procedures are often performed in combination with one another which is always the case when instrumentation or cages are inserted. The code descriptions often include the surgical approach either posterior anterior or posterolateral. In posterior approach surgeries the incision is made in the patient's back. In an anterior approach the incision is made in the abdomen or neck and the surgeon moves organs and viscera to reach the operative site on the anterior or front of the spine. In a posterolateral approach the patient lies on his side and the surgeon accesses the operative site from the back.
Anterior fusions are often the work of two primary surgeons. One opens approaches and closes the surgical site while the other does the actual fusion and instrumentation if applicable. As in the introductions to all the spine codes CPT instructs co-surgeons to append modifier -62 (Two surgeons) to all aspects of the surgery where both worked together as primary surgeons.
Posterior arthrodesis is described by 22590-22632. Arthrodesis codes for spinal deformity are 22800-22819 and generally involve resection or reconstruction of more than one segment of the spine. This may involve shaving and reshaping existing bone to straighten curvature the insertion of bone graft where naturally occurring bone is absent or the insertion of instrumentation to straighten a crooked or curved spine.
The five procedures performed were the following:
The coding debate begins when choosing how to report the procedures. Conventional coding wisdom says to pick the code with the highest relative value units (RVUs) and put it first on the list followed by secondary codes with modifiers if applicable. Heidi Stout CPC CCS-P coding and reimbursement manager for University Orthopaedic Associates in New Brunswick N.J. maintains "Since 22614 is the add-on code for any additional level meaning it does not specify cervical thoracic or lumbar all other fusions after the first level are reported with 22614." Using that approach the coder reports the code with the highest RVU first and continues as follows:
Orthopedic Coding Alert
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