General Surgery Coding Alert

Question: Which CPT code should I use when the surgeon undertakes a thoracotomy to prepare a patient for an orthopedist who performs a spinal fusion?

Delaware Subscriber

Answer: Dont use 32100 (thoracotomy, major; with exploration and biopsy), says Elaine Elliott, CPC, a general surgery coding and reimbursement specialist in Jensen Beach, Fla. Instead, the surgeon should bill the appropriate arthrodesis code (in this case, 22556, arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; thoracic) with modifier -62 (two surgeons) attached.

This can be difficult for surgeons because the orthopedist, who must also bill the procedure with modifier -62 attached, may incorrectly suggest that the surgeon bill using the thoracotomy code. However, Medicare has banned thoracotomy and laparotomy (49000 and 49010) codes for the purpose of exposing the spine, and considers the use of these codes in such procedures unbundling.

Note: If the general surgeon is preparing the patient for a lumbar as opposed to thoracic procedure code 22558 (arthrodesis; ; lumbar) should be reported.

Furthermore, CPT 2001 has introduced new language to the introduction of the Spine section that specifically addresses this situation (in the lumbar region) and defines the appropriate use of modifier -62:

When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by appending the modifier -62 to the single definitive procedure code. If additional procedure[s] (including add-on procedures) are performed during the same surgical session, separate code[s] may be reported by each co-surgeon, without modifier -62 appended.

CPT then goes on to give an example that specifically addresses the billing of arthrodesis co-surgery, as follows:

A 42-year-old male with a history of post-traumatic degenerative disc disease at L3-4 and L4-5 (internal disc disruption) underwent surgical repair. Surgeon A [general surgeon] performed an anterior exposure of the spine with mobilization of the great vessels. Surgeon B [orthopedist] performed anterior [minimal] diskectomy and fusion at L3-4 and L4-5 using anterior interbody technique.

Report surgeon A: 22558-62
Report surgeon B: 22558-62, 22585, 20931.

Note: For a thoracic arthrodesis, substitute 22556 for 22558. The bundling guidelines for both are identical.

If possible, the orthopedists office should be contacted, and billing should be coordinated to avoid potential misunderstandings.

Note: Some Medicare carriers, such as Trailblazer Health Enterprises, the Medicare Part B carrier in Texas, Maryland, Delaware, Virginia and the District of Columbia Metropolitan Area, do not follow these guidelines. According to Trailblazers March 1, 2000, Medicare Part B bulletin:

Medicare has identified inappropriate billing when a general surgeon is performing an anterior exposure in preparation for spinal surgery by an orthopedic surgeon. The procedure should be billed with an unlisted code; however, it is not appropriate to report the -62 or -66 [surgical team] modifier with an unlisted procedure code. An operative report should be submitted to explain the procedure being performed.

. . . We are receiving inappropriate CPT codes billed with the -62, modifier and the operative report does not support the procedure reported. If the procedure involved unusual difficulty, the unlisted procedure code should be billed with the -22 modifier.