Neurosurgery Coding Alert

The surgeon must perform a bone graft to complete a standard PLIF

Posterior lumbar interbody fusion (PLIF) claims always contain at least two CPT codes, and they often include more. Leaving just one of these codes off the claim can cause the practice to miss out on rightful reimbursement.
 
Check out this primer on how to put all of the pieces together correctly for a proper PLIF claim.

Code for Each Interspace the Surgeon Treats
 
During a PLIF, the neurosurgeon will treat one or more vertebral interspaces. Coders must remember to report each interspace treatment in a PLIF encounter separately, says Katherine Phelan, CPC, coding and billing consultant in Tulsa, Okla.

When you are coding for a standard PLIF procedure, you should report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) for the first interspace.
 
Code any additional interspaces with +22632 (- each additional interspace [list separately in addition to code for primary procedure]), says Nancy Reading, RN, BS, CPC, director of educational services for the American Academy of Professional Coders.
 
Remember: Never report 22632 unless you are also reporting 22630, Phelan says. -The 22632 code is an add-on code you use in addition to 22630 when the interbody fusion is performed across more than one interspace,- she says.
 
You-ll also want to be sure to prove medical necessity for the PLIF procedure through precise ICD-9 coding. If you are unsure which ICD-9 codes will provide medical necessity for PLIF, check with your insurer.
 
According to Kathleen Pratt, CPC, coder at Mercy Neurosurgery in Janesville, Wis., these are some of the diagnoses that her insurers accept for 22630 and 22632:

 - 721.3 -- Lumbosacral spondylosis without myelopathy
 - 721.42 -- Lumbar spondylosis with myelopathy
 - 722.52 -- Degeneration of lumbar or lumbosacral intervertebral disc
 - 722.83 -- Postlaminectomy syndrome; lumbar region
 - 724.02 -- Spinal stenosis; lumbar region.

Choose Bone Graft Code Carefully

During the PLIF procedure, the neurosurgeon will need to place bone grafts to stabilize the spine. You-ll choose the bone graft procedure codes from 20930-20938. Pay attention to the surgeon's notes when choosing a bone graft code because the surgeon can perform the bone graft using one of several methods.
 
-The standard in the past with PLIFs was to harvest bone from the iliac crest through a separate incision and code with 20937 (Autograft for spine surgery only [includes harvesting the graft]; morselized [through separate skin or fascial incision]) or 20938 (- structural, bicortical or tricortical [through separate skin or fascial incision]),- Phelan says.
 
The problem with these autografts is that there is potential for both post-op patient pain and chronic pain at the harvest site, she says.
 
Another technique her surgeons might choose is a bone morphogenic protein (BMP) material instead of a PLIF bone graft, she says. When your neurosurgeon uses a BMP material, choose 20930 (Allograft for spine surgery only; morselized) for the procedure.
 
Other bone graft codes possible: Pratt often codes PLIF bone grafts with 20937 or 20930, much like Phelan. On the other hand, Pratt reports she also uses 20936      (- local [e.g., ribs, spinous process, or laminar fragments] obtained from same incision) when the surgeon performs a localized graft.
 
Although Medicare does not pay for this code because it reflects the work of harvesting bone within the exposure, you should report it if the surgeon performs it. Further, non-Medicare payers may have a fee schedule for this procedure.
 
No matter which method the surgeon uses, experts say he will always perform a bone graft during a PLIF procedure. -By definition, a PLIF must include bone grafts. The PLIF just indicates where,- Reading says. Coders will typically use the same ICD-9 code to prove medical necessity for the PLIF procedure and the bone graft, she says.
 
Example: A patient with lumbar spinal stenosis reports to the neurosurgeon for a PLIF procedure. The surgeon performs PLIF at L3-L4 and L4-L5 and also conducts a structural allograft procedure to stabilize the patient's spine.
 
On the claim, you would report the following:

 - 22630 for the L3-L4 interspace.
 - 22632 for the L4-L5 interspace.
 - 20931 (Allograft for spine surgery only; structural) for the bone graft.
 - 724.02 linked to 22630, 22632 and 20931 to prove medical necessity for the procedures.

Some PLIF Patients Also Need Pedicle Screws

During PLIF, the neurosurgeon may need to insert pedicle screws to stabilize the patient. -Pedicle screws reduce the risk of slippage of the bone or interbody cage,- two events that could cause the PLIF to fail, Phelan says.
  
The surgeon may also opt for pedicle screws if the PLIF area looks unhealthy or not viable, Reading says. When the neurosurgeon places pedicle screws during a PLIF procedure, choose from the following codes:
 
If the surgeon fixes screws at a single interspace or at multiple interspaces with two fixation points, report 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]).
 
If the surgeon fixes screws at more than two points, choose from these codes, depending on the situation:

 - 22842 -- Posterior segmental instrumentation (e.g.,  pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments
 - 22843 -- - 7 to 12 vertebral segments
 - 22844 -- - 13 or more vertebral segments.

(Want to know when you can report a laminectomy code in addition to PLIF procedure codes? Check out -Leaving Laminectomy Off PLIF Claim? Not So Fast- at the top of the right column.)