Neurosurgery Coding Alert

Not all spinal grafting codes will reimburse separately

Fail-proof spinal bone graft coding is as easy as learning some basic terminology and paying attention to where the surgeon obtains the material she grafts. If you can answer the following three questions, you can always choose a code with confidence.

1. Autograft or Allograft?

If the surgeon harvests bone from the patient's own body to graft into the spine, you must choose an autograft (autos = -self-) code 20936, 20937 or 20938 (see -Spinal Bone Graft Codes- below for full code descriptors).

For example: The surgeon removes a portion of bone from the patient's rib, reshapes the bone as necessary, and grafts it into the spine for reconstruction.

In contrast, an allograft (20930 and 20931) comes from a human donor (either a living donor or a cadaver) for use in a different human recipient (allos = -other-).

The operating surgeon does not harvest the allograft (although he may shape the bone prior to placing it). Rather, the operating surgeon obtains the previously harvested, frozen or freeze-dried allograft from a surgical or regional bone bank prior to surgery, says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.

If physician documentation mentions that the bone comes from a bone bank, an allograft code is appropriate.

2. If Autograft, Same or Different Incision?

If documentation specifies an autograft, you must next determine if the surgeon harvested the bone from the same incision through which she places the graft, or if she must make a separate incision to harvest the bone.

If the surgeon harvests and places the bone via the same incision--by taking, for instance, bone tissue from the ribs, spinous process or laminar fragments--you may immediately select the -local- autograft code 20936, Sandhusen says.

If the surgeon harvests and removes the bone through a skin or fascial incision, then makes a second, separate incision to place the bone in the spine, you have one more question to answer before you can choose the proper code.

3. Structural or Morselized?

For all allograft procedures, and for any autograft that the surgeon does not harvest and place via the same incision, you must determine if the graft is structural or morselized. A structural bone graft consists of a single piece of bone that provides direct support for skeletal structures.

A morselized (or small-segment) graft consists of several smaller pieces of bone packed together to fill bony cavities, primarily to promote new bone growth, Sandhusen says. For example, following posterior cervical laminectomy and instrumentation, the surgeon may place morselized bone in open areas on either side of the spine and in the facet joint spaces. The surgeon may obtain the morselized graft from a bone bank, or she may prepare the morselized graft in the operating room using bone provided by the bone bank.

You should be able to find documentation of -structural- versus -morselized- easily in the op report.

For a structural autograft, you should select 20938. For a structural allograft, choose instead 20931.

For a morselized autograft, the appropriate code is 20937. For a morselized allograft, turn to 20930.

Example 1: The neurosurgeon performs anterior interbody fusion at that level with minimal discectomy (without decompression), and places a Cornerstone fibular allograft and plate for a patient with C5-C6 degenerative cervical disc disease (722.4, Degeneration of cervical intervertebral disc). In this scenario, report:

- 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2) for the fusion and discectomy

- +22845 (Anterior instrumentation; 2 to 3 vertebral segments) for placement of the plate

- 20931 for the Cornerstone allograft.

Example 2: The surgeon performs a posterior lumbar interbody fusion (PLIF) for stenosis (724.02, Spinal stenosis; lumbar region) and spondylolisthesis (738.4, Acquired spondylolisthesis) at L2-L3 and L3-L4. He harvests bone from the iliac crest, via a separate incision, to prepare and place a morselized graft at each interspace. He fixes pedicle screws at two points (L2 and L4) to stabilize the spine further. To report this procedure, code:

- 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) for the first interspace (L2-L3)

- +22632 (- each additional interspace [list separately in addition to code for primary procedure]) for the additional interspace (L3-L4)

- 20937 for harvesting, preparing and placing the morselized graft

- +22840 (Posterior non-segmental instrumentation [e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation]) for the pedicle screws.
 
Bonus Tip: Include Harvesting and Shaping

Remember that autograft codes are specifically designed to include graft harvesting, says Rena G. Hall, CPC, coder and auditor with KC Neurosurgery Group in Kansas City, Mo. CPT does not contain a separate code to report the harvesting of bone for use in spinal grafts.

Allograft codes do not include harvesting because the surgeon obtains the bone from a bone bank rather than from the patient's own body. Because allografts do not include harvesting, they pay slightly less than otherwise similar autograft procedures.

Finally, all spinal bone grafting codes 20930-20938 include graft shaping or preparation, Hall says.

Avoid These Modifiers

You should never append modifier 50 (Bilateral procedure) to spinal graft codes 20930-20938. The CMS Physician Fee Schedule Database includes a -9- indictor in the -BILAT SURG- column for all codes 20930-20938. According to further CMS instructions, a -9- indicator in this column means that the concept of a bilateral surgery with spinal grafting (20930-20938) -does not apply.-

Likewise, you would never append modifier 62 (Two surgeons), or modifiers 80 (Assistant surgeon), 81 (Minimum assistant surgeon) or 82 (Assistant surgeon [when qualified resident surgeon not available]) to spinal graft codes 20930-20938.

The CMS Physician Fee Schedule Database includes a -9- indictor in the -ASST SURG- and -CO-SURG- columns for all codes 20930-20938. According to further CMS instructions, a -9- indicator in these column means that the concept of an assistant at surgery or co-surgeon with spinal grafting (20930-20938) -does not apply.-

In addition, instructions in CPT explicitly state, -Do not append modifier 62 to bone graft codes 20930-20938.-

Bottom line: For coding and billing purposes, you can't -split- the work of placing spinal bone grafts between two surgeons.

Never append modifier 51 (Multiple procedures) to 20930-20938, because these are modifier-51-exempt add-on codes (see -Make Add-On Code Claims Effortless- on page 13 for complete information on add-on codes).

Be Aware of Possible Non-Payment

Although neither CPT nor CMS officially bundles spinal bone grafts to other procedures, Medicare payers and third-party payers observing CMS guidelines will effectively bundle spinal bone grafts 20936 (autograft including local harvest) and 20930 (morselized allograft) to any related procedure with which you would report them.

The logic: Medicare designates graft procedures 20930 and 20936 as status -B- codes. CMS policy dictates that Medicare payers always bundle these codes into payment for other services. To reinforce this, the national Physician Fee Schedule Database assigns these codes zero relative value units (RVUs).

In other words, Medicare does not preclude you from reporting 20930 or 20936, but it will not pay you for them.

Take-away point: Medicare payers will never reimburse you for 20930 or 20936, regardless of the primary procedure code(s) you claim. And you cannot charge the patient for the disallowed amounts because Medicare has -already paid- you for these services as part of the payment for the primary procedure.

Strategy: Private payers may reimburse 20930 and 20936, so you should not stop reporting these procedures. Your best strategy with Medicare is simply to write off the codes as -disallowed- when Medicare does not pay.

Spinal Bone Graft Codes

- +20930--Allograft for spine surgery only; morselized

- +20931--... structural

- +20936--Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision

- +20937--... morselized (through separate skin or fascial incision)

- +20938--... structural, bicortical or tricortical (through separate skin or fascial incision).