EM Coding Alert

Question: Encounter notes indicate that the surgeon performed an office/outpatient evaluation and management (E/M) service for a new patient that lasted 57 minutes and involved high medical decision making (MDM). Then, they performed posterior spinal arthrodesis on four vertebral segments. How should I report this encounter?

Arkansas Subscriber

Answer: You should report 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.) for the E/M.

Also, append modifier 57 (Decision for surgery) to 99205 to show that the E/M was a significant, separately identifiable service from the surgery during which encounter the decision for surgery was made if the surgery is performed on the same date as the office visit or the following day.

Surgery coding: The arthrodesis coding depends on whether the surgeon was performing the surgery for a spinal deformity or some other condition, when the arthrodesis was performed, and in which region of the spine.

If the surgery was for a spinal deformity you should report 22800 (Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments) for the arthrodesis.

If the posterior spinal arthrodesis is not being performed for a deformity, the correct primary code to apply depends on whether the initial level of arthrodesis is performed in the cervical, thoracic, or lumbar spine.

Go back and check which region the surgeon treated during the initial arthrodesis. Then choose from one of the following codes:

• 22600 (Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment)
• 22610 (… thoracic (with lateral transverse technique, when performed))
• 22612 (… lumbar (with lateral transverse technique, when performed))

Each additional level, regardless of the spinal location, would be reported with +22614 (… each additional interspace (List separately in addition to code for primary procedure)).