EM Coding Alert

Check how the decision for surgery was made.

Coders responsible for reporting osteotomy claims need to be meticulous, or they might miss including certain services in addition to the primary procedure.

Here’s a primer to keep handy if an osteotomy claim hits your desk.

Define Osteotomy

Spinal osteotomy is a surgical procedure that involves the removal of anatomical structures in the spine, such as the lamina and facet joints, to treat deformity. While it is typically performed as part of deformity correction, osteotomy concurrently results in spinal decompression treatment, which would not be separately reportable. Consequently, one would not report a laminectomy at the same interspace level as an osteotomy.

The purpose of spinal osteotomy is to address conditions such as degenerative spondylolisthesis with moderate to severe lumbar spinal stenosis, kyphosis, or scoliosis.

Count on E/M and Imaging in Making Decision

Before your surgeon performs an osteotomy, they will need to make a decision for surgery. This is typically done through a combination of services, explains Joseph Kapurch, MD, at Metropolitan Neurosurgery in Coon Rapids, Minnesota.

An evaluation and management (E/M) service and imaging will likely be the first step toward performing an osteotomy. The physician will likely perform an office/outpatient E/M, which you’d code with 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) Be observant, though; the physician might perform another E/M service — such as hospital inpatient or observation — before deciding on the procedure.

Also, standing X-rays and a computed tomography (CT) scan may be necessary, Kapurch says. When a patient needs more than 10 degrees of correction in a sagittal or coronal plane with some amount of fixed alignment — fusion, disk collapse, trauma — an osteotomy may be indicated. “Almost never would it be needed as a primary treatment; all mine [osteotomy patients] have been in previously fused patients or fracture.”

The codes you’ll choose from for X-rays and CT scans for potential osteotomy patients are:

• Spinal X-ray: 72020 (Radiologic examination, spine, single view, specify level) through 72120 (Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views)
• Spinal CT: 72125 (Computed tomography, cervical spine; without contrast material) through 72133 (Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections)

Don’t Forget to Consider Other Services