anicole76
New
We are having trouble coding a reinsertion of spinal instrumentation and would like to get some feedback. The patient had a cervical discectomy and spinal fusion on 9-5-12 with three level instrumentation (C4-C7). On 9-7-12 the patient returned and it was determined the hardware would have to be removed and reinserted. The operative report states exploration of the anterior cervical spine was performed with removal of the old cervical plate and screws, and new hardware inserted at the same levels as the initial surgery. We coded the 9-7-12 surgery with CPT 22830 for the exploration and 22846 for the reinsertion. The exploration was paid and reinsertion denied (22846) stating it was billed without a primary procedure. Our thoughts were the exploration would be the primary procedure for this encounter. We would appreciate any feedback regarding experience with coding this scenario. Thank you very much!