Spinal hardware removal with reexploration, reinsertion
Q: My surgeon performed a removal of spinal hardware, with reexploration and reinsertion all at the same level. Can I bill for all three procedures?
A: In most cases, No.
Although CPT 2005 appears to instruct you to list the reinsertion of spinal fixation device (22849) code, the removal codes (22850, 22852, 22855) and code 22851 (Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate)) “separately, in conjunction with code(s) for fracture, dislocation, arthrodesis or exploration of fusion of the spine” (22830), this is misleading. The most recent National Correct Coding Initiative (CCI) edits restrict you. CCI 11.2 pairs 22850, 22852 and 22855 as Column 1 codes with 22830 in Column 2. That means if you report these pairs of codes together, you’ll be reimbursed for the removal procedures, not exploration. The codes are modifier-approved (status indicator 1) when appropriate, however.
Exploration is a routine part of surgery, and typically is considered included in the more comprehensive procedure. According to the CCI Manual (chapter 4):
“Codes describing independent exploratory services are not to be reported when a more comprehensive procedure is being performed in the same area. Specifically, an exploration code such as CPT code 22830 (exploration of spinal fusion) is not reported with other procedures involving the spine unless performed at a different site/different incision from the other procedure(s). If, for example, a cervical spine procedure was being performed, and, at the same operative session, a lumbar fusion was explored through a separate incision, the CPT code 22830-59 could be reported assuming the requirement for medical necessity was satisfied.”
CPT 2005 instructs you not to report reinsertion of spinal fixation device (22849) with the three spinal instrumentation removal codes (22850, 22852, 22855) at the same spinal levels. CCI 11.2 also pairs 22849 in Column 1 with 22850, 22852 and 22855 in Column 2. But the three removal codes and 22849 can be appended by the -51 modifier “if reported with other definitive procedure(s), including arthrodesis, decompression, and exploration of fusion,” CPT says. Note, however, that CPT code 22851 is modifier -51 exempt, and should be reported only once, regardless of the number of metal cages placed. According to CPT Assistant (September 1997):
“It is important to note that CPT code 22851 is not intended to be reported per cage. CPT code 22851 should only be reported one time, regardless if one or more metal cages are placed in the intervertebral space at the same level. However, if metal cages are placed at two different levels, (eg, metal cage placed at L3-4 interspace and L5-S1 interspace), then 22851 may be reported more than once to indicate that one or more cages were placed at two or more different levels. It is important to note that a single cage or methylmethacrylate can cover a defect of several vertebral segments (eg, a single cage may replace three entire vertebrae), wherein code 22851 would still only be reported one time.”
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