# Coding help needed - coding for a Ortho



## kathydaniel (Feb 16, 2010)

I've just started coding for a Ortho doc and was wondering if I could get some advice.  He previously billed for a spine surgery and now he's wanting me to work on the denials.

Procedures:
1. Laminectomy decompression, L2-3
2. Posterior spinal fusion with Aesculap fixation L2-3, L3-4, L4-5 and L5-S1
3. Removal of lumbar fixation L3-4 plate and screws on left, L4-5 and S1
4. Exploration lumbar fusion with documentation of pseudoarthrosis
5. Local and demineralized bone graft.

The technical procedure:
The pt is brought to the op suite, general anesthetic admin, placed prone on a Jackson frame.  ChloraPrep followed with a sterile drape,  Midline incision opened, carried through its extent through subcutaneous tissue.  Paraspinal muscles elevated with Bovie electrocautery and Cobb elevator.  Meticulous dissection around the previous implant, I noticed peri-implant wear, debris and a loose pedicle screw on the right at the S1 level.  The left S1 pedicle screw is broken.  The hardware is completely removed with the universal extractor set.  Fusion explored directly and stressed with laminar spreader.  It is found to be solid at L3-4 but a pseudoarthrosis at L4-L5 and L5-S1 subsequently evlauated and diagnosed.  After the hardware was all removed, I replaced fixation at L2-3 with a standard awl blunt gearshift type probe, surface anatomy tactile probing of pedicle, stimulus induced free-running EMG and lateral fluoroscopy.  Good implant alignment and positioning noted with this fluoroscopy.  I use a variety of Aesculap pedicle screws, L2, L3, L5 and S1 levels bilaterally.  My initial intent was going to be to remove the fractured portion of the screw at S1 on the left.  However, as I was removing the screw the idea became apparent to place another screw directly adjacent to it and rather than have a huge hole that has to be filled by upsizing the screw or some other technique, cementing it or whatever, I was able to put a screw right adjacent to the previous broken one and use that broken fragment for stability of the secondary screw placed next to it.  It worked very well.  A tight 8mm Aesculap screw by 50 in length was placed and under fluoroscopic guidance with excellent bony purchase.  At this point, the wound is thoroughly irrigated.  Laminectomy decompression completed at L2-3.  High-grade stenosis initially burred with the Anspach drill and ultimately scar is picked from the dura with an angled curet until I can get a Kerrison punch into position to perform midline laminectomy, mesial facetectomy bilaterally.  This being completed, a nice decompression established of the stenotic level.  Now, the stabilization is completed with 120 mm rods, bent to conform to good lumbar lordosis to prevent further adjacent segment decompensation.  The wound thoroughly irrigated and the rod applied with the Aesculap set nuts to 10 Newton meters.  The posterolateral bed thoroughly decorticated with a 5 mm bur and the Anspach drill and packed with local bone graft from the laminectomy site, two of the 10 cm packs of fiber-based demineralized bone matrix and infuse bone morphogenic protein.  At this point, the crosslink applied.  Good implant alignment positioning with fluoroscopy.  The procedure was terminated.  The incision closed with a locked running watertight fascial closure to the fascia, subcu fat is approximated, skin closed with a running intradermal cosmetic stitch and Dermabond.  The patient is awakened, taken to recovery stable.

They billed:
22612
22614
22614
63047
22830-59 DENIED
22852-59 DENIED
20936 DENIED
22842

I understand the 22830-59 denial because you can't bill that if it's performed at the same incision site.  I don't understand why they didn't pay for the removal of the old instrumentation or the bone graft.

Any advice you can give me on the appeal I would greatly appreciate!!

Kathy


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## sphillips79 (Feb 16, 2010)

In my experience with spine (which isn't that much) on the professional side, is that if they are removing it due to failure and replacing it with new then it wouldn't be payable. but like I said I don't have that much experience with professional, I bill hospital and all of my spine cases are DRG.


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## RebeccaWoodward* (Feb 16, 2010)

Procedures:
1. Laminectomy decompression, L2-3
2. *Posterior spinal fusion with Aesculap fixation L2-3, L3-4, L4-5 and L5-S1*
3. *Removal of lumbar fixation L3-4 plate and screws on left, L4-5 and S1*
4. Exploration lumbar fusion with documentation of pseudoarthrosis
5. Local and demineralized bone graft.


You've removed (22852) instrumentation at the same levels (L3-L4, L4-L5, S1) that you replaced instrumentation (22842).  Typically, when you see a removal, exploration and replacement of instrumentation for the same levels, you code 22849.

Reviewing the CCI edits for 22612, 22614, 22849, 63047, there aren't any bundling issues.  The RVU's are also higher for 22849 as opposed to 22842. (there is extra work involved)

"*Coding for Revision Spinal Surgery*
Additional difficulties in proper coding are encountered when revision spinal surgery is performed. For example, a revision of a prior fusion may include procedures such as exploration of a fusion (22830), removal (22852), reinsertion (22849), or placement of spinal instrumentation (22840-22844), and performance of a fusion at the same or adjacent levels (22612, 22614, 22630, 22632). The CMS has used National Correct Coding Initiative edits for years to preclude payment for an exploration of fusion with arthrodesis, despite introductory language in CPT that specifically identifies arthrodesis and instrumentation as separate physician work. Although an exploration of fusion and arthrodesis at the same level should be considered inclusive, arthrodesis at adjacent levels is separately identifiable and the arthrodesis code should be appended with the –59 modifier. *If spinal instrumentation is removed and replaced at the same levels, only code 22849 should be used, rather than a removal code and an insertion code."*

http://www.aans.org/Library/Article.aspx?ArticleId=40529

As for the bone graft...many of our carriers do not pay for these.  Medicare does not and carriers tend to follow their guidelines.

Anyone else have a thought on this case?


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## kathydaniel (Feb 16, 2010)

Thank you!


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## RebeccaWoodward* (Feb 16, 2010)

There is also a CPT Assistant article on this that could be of help...12-05 I think...


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