Wiki Anterior cervical fusion

[Blackhorse]

POSTOPERATIVE DIAGNOSES Cervical stenosis with cervical radiculopathy C5-6 on the left, cervical spinal stenosis C5-C6

PROCEDURES:

1. Complete anterior cervical discectomy C5-C6.
2. Anterior cervical fusion C5-C6.
3. Anterior cervical instrumentation two levels Aesculap ABC plate
4. Anterior Insertion of intervertebral tricortical allograft
5. Demineralized bone matrix

OPERATIVE DETAIL: The patient was placed on a well-padded operating table. The anterior approach to his cervical spine was completed incising the skin along the medial border of the sternocleidomastoid. The platysma was located and opened, and dissection down through to the prevertebral fascia was completed, taking care not to injure any neurovascular structures keeping the carotid artery to the lateral portion of spine, and the trachea and esophagus medially. Once the cervical spine was located and exposed the indirect fluoroscopy was used to verify the level. Once that was done, the longus colli was elevated off the anterior cervical spine. Retractors were put into place under the anterior longus colli. The Caspar pins of 14 mm were put into the vertebrae above and below the discs to be treated. X-rays confirmed position and the complete discectomy was done. Decompression was completely done all the way to the neural foramen and centrally in the canal. There was a moderately-sized left posterior lateral disc herniation that extended into the neural foramen. After that decompression was completed the right neuroforamen was probed. The neural foramina was patent. After hemostasis was achieved and the endplates were prepared and removed the endplate cartilage then the disc space was measured for the anterior interbody fusion device. The anterior osteophytes were removed. The interbody space was measured and a tricortical allograft wedge was cut to size and prepared by placing DBM within and put into position with hammer and tamp. The patient had been given Decadron in the procedure at this point as well. Once all levels were completed and the plate was measured put into position, held in place with one or two screws and x-rays confirmed position, additional screws were put in, torqued down to manufacturer's recommendations. The wounds were irrigated after the Caspar pins had been removed, hemostasis was achieved. Gel-foam was placed on the cervical plate with 40mg of kenalog to assist in dysphagia prevention. The platysma was closed with 3-0 undyed Vicryl on the subcutaneous, 4-0 Biosyn subcuticular, Indermil over top. Sterile dressing was applied. The patient was then awakened and taken to the PACU for recovery.

CPT I use are 22551, 22845. For the tricortical allograft DBM, I'm not sure if I need to code 20930 or 20931, is the allograft morselized or structural?

 

[Yamelis]

I would used 20931 to report the tricortical allograft. Below is some information from AAPC that can help you with spinal bone graft coding.

Spinal Bone Graft Coding, as Easy as 1, 2, 3

If you can master basic terminology and identify within documentation the answer to three key questions, you can accurately apply spinal bone graft codes.

www.aapc.com

If you can master basic terminology and identify within documentation the answer to three key questions, you can accurately apply spinal bone graft codes.
1. Is the Bone Graft from the Patient’s Own Body?
Bone harvested from the patient’s own body is known as an “autograft.” For spinal grafts, the applicable autograft codes are:

+20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)
+20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
+20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

Note that all of the above codes include harvesting of the bone, which is not separately reported, as well as shaping or preparation of the graft, prior to placement.
If the bone for the graft comes from a bone bank or donor other than the patient, it is an allograft. The spinal allograft codes are:

+20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)
+20931 Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)

Like 20936-20938, the allograft codes include shaping or preparation of the graft material.
2. Where’s the Incision?
When coding for spinal autograft only, you must also determine whether the bone for the graft is harvested from the same site into which the graft will be placed, or from a separate site.
When the surgeon harvests and places the bone via the same incision, select the “local” autograft code, 20936. When the bone is harvested from a different incision, or when using allografts, you must answer an additional question.
3. Is the Graft Structural or Morselized?
Morselized bone grafts are small pieces of bone used to pack defects and to promote new bone growth. For a morselized autograft, choose 20937. For a morselized allograft, select 20930.
A structural bone graft is a single piece of bone, which provides direct support for skeletal structures. For a structural autograft, select 20938. For a structural allograft, report 20931.
Threaded bone dowels are an exception: Per CPT® Assistant (February 2005), “Threaded bone dowel is the only bone allograft that would qualify for code 22851 [Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)].”
Bonus Tip: Multiple Grafts and Modifiers
You may report a maximum of one unit of any spinal bone graft code, per session, even if the surgeon places multiple spinal bone grafts. CPT® Assistant (April 2012) instructs, “When more than one type of bone graft is required, the appropriate code(s) from the 20930-20938 series are reported only once per operative session, regardless of the number of vertebral levels being surgically fused (i.e., not once per spinal interspace or segment fused).” For this same reason, you should never append modifier 50 Bilateral procedure to bone graft codes 20930-20938.
Per CPT® instructions, you should not append modifier 62 Two surgeons to bone graft codes 20930-20938. And, because 209930-20938 are add on codes, you would never report them with modifier 51 Multiple procedures appended.

 

[Blackhorse]

I would used 20931 to report the tricortical allograft. Below is some information from AAPC that can help you with spinal bone graft coding.

Spinal Bone Graft Coding, as Easy as 1, 2, 3

If you can master basic terminology and identify within documentation the answer to three key questions, you can accurately apply spinal bone graft codes.

www.aapc.com

If you can master basic terminology and identify within documentation the answer to three key questions, you can accurately apply spinal bone graft codes.
1. Is the Bone Graft from the Patient’s Own Body?
Bone harvested from the patient’s own body is known as an “autograft.” For spinal grafts, the applicable autograft codes are:


Note that all of the above codes include harvesting of the bone, which is not separately reported, as well as shaping or preparation of the graft, prior to placement.
If the bone for the graft comes from a bone bank or donor other than the patient, it is an allograft. The spinal allograft codes are:


Like 20936-20938, the allograft codes include shaping or preparation of the graft material.
2. Where’s the Incision?
When coding for spinal autograft only, you must also determine whether the bone for the graft is harvested from the same site into which the graft will be placed, or from a separate site.
When the surgeon harvests and places the bone via the same incision, select the “local” autograft code, 20936. When the bone is harvested from a different incision, or when using allografts, you must answer an additional question.
3. Is the Graft Structural or Morselized?
Morselized bone grafts are small pieces of bone used to pack defects and to promote new bone growth. For a morselized autograft, choose 20937. For a morselized allograft, select 20930.
A structural bone graft is a single piece of bone, which provides direct support for skeletal structures. For a structural autograft, select 20938. For a structural allograft, report 20931.
Threaded bone dowels are an exception: Per CPT® Assistant (February 2005), “Threaded bone dowel is the only bone allograft that would qualify for code 22851 [Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)].”
Bonus Tip: Multiple Grafts and Modifiers
You may report a maximum of one unit of any spinal bone graft code, per session, even if the surgeon places multiple spinal bone grafts. CPT® Assistant (April 2012) instructs, “When more than one type of bone graft is required, the appropriate code(s) from the 20930-20938 series are reported only once per operative session, regardless of the number of vertebral levels being surgically fused (i.e., not once per spinal interspace or segment fused).” For this same reason, you should never append modifier 50 Bilateral procedure to bone graft codes 20930-20938.
Per CPT® instructions, you should not append modifier 62 Two surgeons to bone graft codes 20930-20938. And, because 209930-20938 are add on codes, you would never report them with modifier 51 Multiple procedures appended.

Thank you so much for such detailed explanation for bone grafting. I appreciate your help

 

[amyjph]

You can look at the hospital record (if you have access) and see the manufacturer and name of the DBM, etc. Sometimes the provider will state the brand name in the op note. You can usually figure it out by googling on the manufacturer site, etc. for more information on the graft if you need more info.

Just an example: Bone Grafting - Spinal and Orthopaedic

 

[Blackhorse]

You can look at the hospital record (if you have access) and see the manufacturer and name of the DBM, etc. Sometimes the provider will state the brand name in the op note. You can usually figure it out by googling on the manufacturer site, etc. for more information on the graft if you need more info.

Just an example: Bone Grafting - Spinal and Orthopaedic

Great link for bone grafting. Thanks a lot