Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
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When a spinal fusion is performed, the first thing a coder needs to recognize is the approach or technique that was utilized. With an anterior (front of the body) approach to a cervical fusion the incision will be made in the patient's neck, so the key terms to look for are platysma, esophagus, carotid and sternocleidomastoid. These structures will be divided and/or protected during dissection down to the vertebral body. For the purpose of this discussion, the example will refer to an anterior arthrodesis procedure at the C5-C6 level.
After dissection, the procedure can proceed in one of three ways:
- When the interspace is prepared (minimal discectomy, perforation of endplates) then 22554 would be reported.
- When a discectomy is performed to decompress the spinal cord and/or nerve root(s) report 22554 for the arthrodesis along with 63075 for the discectomy procedure.
- When a partial corpectomy (vertebral body resection) is performed at C5 and C6 report CPT code 22554 for the arthrodesis with 63081 and 63082. Two codes are reported because the corpectomy procedure is performed on two vertebral segments. CPT codes 63081-63091 include a discectomy above and/or below the vertebral segment, so code 63075 (discectomy) would not be reported if performed at the C5-C6 interspace.
Once the decompression procedure has been completed, a PEEK cage can be placed within the interspace or a structural bone graft can be fashioned to fit the vertebral defect created by the previous corpectomy. Insertion of the PEEK cage would be reported with a biomechanical device code 22851. This code is only reported one time per level even if two cages are placed at C5-C6. When a structural bone graft is used, determine whether it is an allograft (20931) or an autograft (20938). The bone graft codes are only reported one time per procedure and not once for each level. Finally, the physician will place an anterior plate with screws (22845) across the C5-C6 interspace to stabilize the area of fusion.
Spinal procedures can be a coding challenge, but a coder's ability to identify these "key terms" will reinforce their confidence and prepare them for mastering this challenge.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Other recent coding stories from Paul Cadorette:
- PRP for the Treatment of Plantar Fasciitis
- Use of New Facet Injection Codes for 2010
- Partial Mastectomy or Lumpectomy with Axillary Lymphadenectomy