Orthopedic Coding Alert

Question: During the same operative session, the orthopedic surgeon performed the following procedures: L4-L5 discectomy, L5-S1 discectomy, L4-L5 transforaminal interbody fusion using posterior interbody technique, L5-S1 transforaminal interbody fusion using posterior interbody technique, bone graft placement (local autograft), L4-L5 interbody cage placement, L5-S1 cage placement and L4, L5, S1 bilateral pedicle screw instrumentation. How should I report this encounter?

Codify Subscriber

Answer: From the description you provide, your surgeon likely performed a transforaminal lumbar interbody fusion (TLIF) procedure. On your claim, report the following:

• 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) for the L4-L5 arthrodesis
• +20936 (Autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinous process, or laminar fragments] obtained from the same incision [List separately in addition to code for primary procedure]) for the autograft
• +22632 (... each additional interspace [List separately in addition to code for primary procedure]) for the L5-S1 interbody fusion
• +22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cage[s], methylmethacrylate] to vertebral defect or interspace [List separately in addition to code for primary procedure]) for the interbody cage insertion at L4-L5
• +22851 for the L5-S1 cage placement
• modifier 59 (Distinct procedural service) appended to the second +22851 to show that you are coding for cage insertions at different levels
• +22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure]) for the screw instrumentation. Because the code’s descriptor refers to “3 to 6 vertebral segments,” you can report only one unit of this code, despite the fact that the surgeon inserted screws at three levels.

Omit laminotomy codes: Because your surgeon only documented a simple discectomy (meaning the discectomy was a preparation for the fusion, not for decompression), you wouldn’t report codes 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar) and +63035 (... each additional interspace, cervical or lumbar [List separately in addition to code for primary procedure]).