Wiki Re-do of Acdf

[malpem20]

Can someone help me out here? I am having some trouble agreeing with my neurosurgeon on how to code one of his ACDF's

Please see the procedure below:

Procedures Performed:
1. Removal of C4, 5, and 6 anterior instrumentation
2. C3-4 anterior diskectomy
3. C3-4 anterior interbody arthrodesis
4. C4-5 revision anterior interbody arthrodesis
5. Reoperation left iliac crest tricortical structural allograft harvest x2
6. Preparing iliac crest tricortical graft for an insertion at C3-4 and C4-5
7. Anterior instrumentation C3, 4, 5, 6

This is how he wants it coded:

22551
63081 (or unlisted procedure code here)
22846
22855
20938

I do not agree. I believe it should be coded around these lines:
63081
22551-51-59
22849-59
22845
22853
20938

He does not agree with code 22849 because he states that was not the procedure performed. He thinks we should not use this code because we added a level to the arthrodesis. Would I have to code the 22849 for the levels that are being removed and reinserted (he is not using the same instrumentation at all)? and code 22551 for the new level done?

He consistently wants me to use an unlisted procedure code for redos of different operations as opposed to using the actual code with the appropriate modifiers. I cannot seem to get unlisted procedure codes paid, therefore i do not want to use them. Any help is greatly appreciated!! We've been over this so many times now my brain just feels like mush and I cannot even begin to think how to code this!

 

[coder1965]

Redo of ACDF

In terms of the instrumentation, I would follow the advice provided by the AMA in CPT Assistant June 2012, Volume 22, Issue 6, pages 10-11, 17:

The appropriate spinal instrumentation insertion code is the only code that should be used when a previously placed spinal instrumentation device is removed or changed during the same session as new instrumentation, even if the insertion includes new levels and/or is part of the previously instrumented segments. In addition, the guidelines specify that reinsertion (22849) and/or removal (22850) should not be additionally reported with the insertion of new instrumentation (22840-22848).

Also your question and proposed codes notes using CPT 63081. Again, CPT Assistant provides guidance on use of this code:
Frequently Asked Questions (June 2015, Volume 25, Issue 6, pages 10, 11)

Question: When performing an anterior cervical discectomy and fusion at C4-C5 and C5-C6, how much of the vertebral body must be removed to appropriately report code 63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment?

Answer: In order for the procedure to be reported as a corpectomy, half of the vertebral body must be resected. Typically, the resected area includes the disc space above and below.

Hope these references help

 

[sarab86]

First, I would not code 63081 unless he specifically states that he is performed a Corpectomy and removing the appropriate % of vertebral body. From looks of it he only did an ACDF so you would only bill 22551 for that portion(C3-4). 22551 includes the decompression done. If all that is done at C4-5 is the arthrodesis, then you would bill 22554-59 showing separate procedure. 22554 s the anterior fusion without decompression.

Secondly, you can only bill 22849 is you are removing and replacing instrumentation at all the SAME levels. If you extended at any point above or below, it does not qualify. In this case you would only be able to bill 22845 and the cages 22853x2.

When my providers do a case list this, I bill 22551 with a modifier 22 for the additional work required to remove the prior instrumentation. You will have to show the OP note to prove additional work and risk to the patient. I usually have to appeal for more money.