Spinal Hardware Removal

lhanshew

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If the surgeon removes fusion hardware at the L4(locking cap, portion of rod, tulip head, and pedicle screw) in a patient with a history of fusion L4 - S1 can we code 22830 for Exploration of Fusion? During the procedure, the surgeon states "The fusion bed at this level appeared to be robust without evidence of hardware failure."
 

mhstrauss

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If the surgeon removes fusion hardware at the L4(locking cap, portion of rod, tulip head, and pedicle screw) in a patient with a history of fusion L4 - S1 can we code 22830 for Exploration of Fusion? During the procedure, the surgeon states "The fusion bed at this level appeared to be robust without evidence of hardware failure."


If instrumentation removal and exploration are performed at the same level, exploration is included in removal, per NCCI edits. Also, here's an older thread with a trusted resource discussing same issue.

https://www.aapc.com/memberarea/forums/22264-code-22830-22852-a.html
 

lhanshew

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Sorry... Forgot to mention that this is private/commercial insurance therefore, NCCI edits may not apply in this case. CPT book seems to instruct to bill 22830 in addition to code for removal 22850/52. I just want to make sure I am clear on this. Thank you so much for your reply!
 
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