Neurosurgery Coding Alert

If the surgeon removes instrumentation to necessitate an exploration of fusion, you cannot charge for the instrument removal, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

On occasion, however, the surgeon may have to remove spinal instrumentation because the instrumentation breaks, the patient's body rejects it, or the patient requires an adjustment in the instrumentation type. In these cases, you can separately code the instrumentation removal, as follows:

If removal occurs after the 90-day global period of the placement procedure (for instance, when the desired anatomic correction has occurred after the instrumentation has remained in place for some time), you may report any of the above codes with no modifiers attached, Przybylski says.

Payment note: "Codes for reinsertion and/or removal are subject to modifier 51 (Multiple procedures) if reported with another definitive procedure," says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network. Therefore, multiple-procedure reductions are appropriate if the removal or reinsertion occurs during the same operative session as a more definitive procedure.

If a return to the operating room is necessary during the 90-day global period of another procedure because the patient's body is rejecting the instrumentation, you should append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the appropriate removal code.

Reinsertion follows the same guidelines: Reinsertion (22849) may be necessary when a spinal fixation device fails due to breakage, loosening, etc. The same modifiers apply when the surgeon performs reinsertion after or during the 90-day global period of another procedure as in the above situations.

When the surgeon must remove instrumentation due to a failed fusion, removal may be accompanied by fusion exploration (22830, Exploration of spinal fusion). Due to national Correct Coding Initiative (CCI) bundling edits, however, surgeons may wish to forgo reporting 22830 if significant spinal reconstruction is necessary following removal of instrumentation.

Best practice: Reserve 22830 for those instances when exploration of spinal fusion does not require removal or further reconstruction, including arthrodesis.