Neurosurgery Coding Alert

Mastering terms and modifiers makes the difference

If you're bewildered by the mysteries of spinal instrumentation, take heart: Instrumentation claims are quite simple if you know whether the procedure is anterior or posterior, segmental or nonsegmental and when to apply a modifier. Our experts offer the following five tips to help you improve your instrumentation coding.

1. Select Instrumentation Codes by Type and Location

When selecting among the spinal instrumentation codes (22840-22855), you should first determine the type of device the physician placed, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb. The two most common types of instrumentation are:

A. Anterior instrumentation (22845-22847), which attaches to the front portion of the spine or vertebral segment (in other words, toward the "center" of the body), and

B. Posterior instrumentation (22840, 22842-22844), which attaches to the back of the spine or vertebral segment.

Look to the operative report for guidance: Generally, the type of instrumentation will correspond to the surgical approach (anterior or posterior). And, the surgeon's documentation should explicitly state the type of instrumentation he or she places. If the surgeon's operative report does not specify, be sure to ask.

Here's an easy way to determine segmental from nonsegmental: If the surgeon places posterior instrumentation, you must further determine if the device is segmental (22842-22844) or nonsegmental (22840).

The surest way to do this is to count the number of fixation points, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. If the surgeon attaches the instrumentation to the spine at only two points, the device is nonsegmental (regardless of the number of vertebrae spanned). If the surgeon attaches the device to at least three points (on three different segments), the instrumentation is segmental.

In some cases, the surgeon will place a metal cage or other prosthetic device for stabilization in an area where he has removed a large portion of the vertebra. This represents a third type of instrumentation, which you should report using 22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace). Report only a single unit of 22851, regardless of how many devices the surgeon places at one level, Sandham says. If the surgeon places devices on multiple spinal levels, however, you may report multiple units of 22851 (one unit for each individual spinal level).

Coding example: The surgeon places two cages at level T6. Report 22851 x 1. Alternatively, the surgeon places two cages at level T6 and a third cage at level T5. Report 22851 x 2. Some payers may require you to append modifier -59 (Distinct procedural service) to the "additional" units of 22851 to distinguish them as occurring at a separate anatomic location(s).

2. Count Levels and Interspaces Carefully

Because CPT defines codes for segmental and non-segmental (both anterior and posterior) instrumentation according to the number of vertebral segments involved (for example, the descriptor for 22842 specifies "... 3 to 6 vertebral segments"), you must count your vertebra carefully, Bucknam says.

Remember: There are seven cervical vertebrae, 12 thoracic (dorsal) vertebrae and five lumbar vertebrae (plus the sacrum).

While CPT defines instrumentation procedures according to vertebral segments, it defines fusion (arthrodesis) procedures (which must accompany instrumentation claims) according to vertebral interspaces, so you must be careful to avoid confusion. For example, the span T12-L4 contains five vertebral segments (T12, L1, L2, L3, L4) but only four vertebral interspaces (T12/L1, L1/L2, L2/L3, L3/L4).

Coding example: The surgeon performs arthrodesis at interspaces C6/C7, C7/T1 and T1/T2. The surgeon then places anterior instrumentation attached at C6 and T2. In this case, report 22554 (Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2), 22556-51 (... thoracic) and +22585 (... each additional interspace [list separately in addition to code for primary procedure]) for the arthrodesis and 22846 (Anterior instrumentation; 4 to 7 vertebral segments) for the instrumentation.

3. Don't Apply Modifiers for Initial Surgery

You should not append modifiers -50 (Bilateral procedure), -51 (Multiple procedures) or -59 to codes describing spinal instrumentation (except to denote different levels for cage placement, as noted above).

CPT defines instrumentation procedures as inherently bilateral, so you should never use modifier -50, Bucknam says.

And, although not "add-on" procedures (see "4 Pointers Make 'Add-on' Codes Easy,"), all codes describing placement of instrumentation (22840-22848, 22851) are exempt from multiple-procedure (modifier -51) adjustments, according to CPT. Because a surgeon would never report instrumentation alone (at minimum, he would also perform arthrodesis), the value assigned to these codes already takes into account their status as "additional" but independent procedures. For the same reasons, you needn't append modifier -59 to instrumentation codes you report at the same time as other spinal procedures.

4. Do Apply Modifiers for Follow-up Surgery

When reporting follow-up instrumentation procedures during the 90-day global period of an initial surgery, you may need to use modifiers, Sandham says.

To make modifier use easy, follow these guidelines and examples:

A. If the surgeon must return the patient to the operating room to remove instrumentation during the global period (for instance, if the patient's body rejects the device, or the spine fails to fuse), append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the removal code.

Coding example: For removal of posterior non-segmental instrumentation during the global period of the initial surgery, report 22850-78.

B. If the surgeon must perform an unrelated procedure to the spine during the global period of a previous fusion/instrumentation placement, append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to the appropriate procedure code.

Coding example: If the surgeon must perform a fusion of cervical vertebrae during the global period of a thoracic fusion/instrumentation, report 22554-79.

C. If the surgeon removes instrumentation from a previous surgery (for which the global period has expired), you need not append any modifiers.

Coding example: One year after placing segmental instrumentation, the surgeon returns the patient to the operating room, removes the instrumentation and performs additional fusions. Report 22852 (Removal of posterior segmental instrumentation).

5. Report Arthrodesis, Bone Grafts Separately

When reporting instrumentation codes, be sure to report arthrodesis procedures, as well as bone grafts, separately. Neither CPT, CMS nor the National Correct Coding Initiative bundles these procedures: Each of these procedures is distinct and deserves separate payment, Sandham says.