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Spine coders-please help!

  1. #1
    Default Spine coders-please help!
    Medical Coding Books
    How would I correctly code this case?
    dx: 723.1,733.82,722.0
    Operation(s) performed: Removal of segmental instrumentation anterior spine, exploration of arthrodesis, debridement of pseudoarthrosis C6-7, revision anterior diskectomy C6-7, revision anterior fusion C6-7 with Cornerstone SR allograft, INFUSE, and anterior cervical plating 25mm Atlantis Vision plate, closure of wound and then a second surgical procedure with new incision C3-4 anterior cervical diskectomy and fusion with allograft INFUSE and plating, SSEP and EMG monitoring.

    Thanks,
    Judy

  2. #2
    Default Anterior spinal procedure
    HI Judy,
    I will give this a shot;
    Removal anterior segmental instrumentation: 22855
    Exploration of fusion (arthrodesis): 22830
    Revision anterior C6-7 diskectomy: 63075 (initial same as revision)
    Anterior cervical diskectomy C3-4 : 63076 (additional level)
    Anterior cervical plate: 22845
    Anterior fusion: C3-4, C6-7: 22554, 22585
    Cornerstone SR allograft: 20931
    INFUSE BMT: 20930


    Quote Originally Posted by JD001 View Post
    How would I correctly code this case?
    dx: 723.1,733.82,722.0
    Operation(s) performed: Removal of segmental instrumentation anterior spine, exploration of arthrodesis, debridement of pseudoarthrosis C6-7, revision anterior diskectomy C6-7, revision anterior fusion C6-7 with Cornerstone SR allograft, INFUSE, and anterior cervical plating 25mm Atlantis Vision plate, closure of wound and then a second surgical procedure with new incision C3-4 anterior cervical diskectomy and fusion with allograft INFUSE and plating, SSEP and EMG monitoring.

    Thanks,
    Judy

  3. Default
    I agree w/ Nelson except I would bill 22849 for reinsertion of original instrumentation C6-7 (which includes the removal) not 22855. Also the exploration of the C6-7 fusion would bundle in with the procedures you are doing on the same level. You can only bill an exploration if nothing else is being done on that level.
    Hope this helps.

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