Neurosurgery Coding Alert

Here's how to break down fusions to improve billing

If you're reporting posterior lumbar interbody fusion (PLIF) with a single code, you're passing up legitimate reimbursement. Here's what you need to know to bill separately for bone grafts, instrumentation and, on occasion, additional fusion procedures.

For Additional Posterolateral Fusion, Report 22612

Not all PLIF procedures are created equal. You should report a "basic" PLIF procedure with code 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar), 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.
 
Sometimes, however, the neurosurgeon also performs a posterolateral fusion. In such cases, you should report 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) as the primary code and list 22630-51 (Multiple procedures) as an additional procedure, the American Association of Neurological Surgeons (AANS) states. The use of modifier -51 identifies the posterolateral fusion as a secondary procedure during the same operative session.
 
For example, a neurosurgeon performs PLIF with diskectomy, using an iliac crest graft for fusion at L5-S1 interspace. And, the surgeon performs an L5-S1 posterolateral fusion and pedicle screws. In this case, the posterolateral fusion (22612) is separate and distinct from the posterior interbody fusion because - even though the posterolateral fusion occurs at the same interspace - it is a different part of the joint. Therefore, you may report 22612 and 22630-51.

Don't Forget Bone Grafts and Pedicle Screws

When a neurosurgeon performs an arthrodesis (22630 and 22612), don't make the common coding error of not billing for the bone graft. The most common graft code with PLIF is 20931 (Allograft for spine surgery only; structural) for bone that came from a bone bank, or 20938 (Autograft for spine surgery only [includes harvesting the graft]; structural, bicortical or tricortical [through separate skin or fascial incision]) for bone that came from the patient's body, says Kee D. Kim, MD, associate professor with the department of neurosurgery at the University of California, Davis.
 
You should also code for the pedicle screw fixation that the surgeon uses to stabilize the spine, Kim says. In the above example, for instance, the physician performs the pedicle fixation across one interspace (L5-S1). To report the pedicle fixation, use 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]). You are not required to append modifier -51 to instrumentation codes, according to CPT guidelines.