Neurosurgery Coding Alert

You need to avoid duplicates in inclusive services. Here’s why.

Spinal coding may pose a challenge as your surgeon often does more procedures than one, requiring you to proceed one step at a time to capture all services and accurately assign the codes. Here is a stepwise approach for spinal procedures and let the following example guide you to more efficient spinal coding.

Example: In a patient with lumbar spondylosis, the surgeon performed the following procedures for spinal surgery:

• Left L4-5, L5-S1 facetectomy with hemilaminectomy of L5 and redo decompression L5-S1 on the left
• L4-5, L5-S1 left transforaminal interbody arthrodesis with structural allograft and autograft
• Segmental pedicle screw instrumentation L4 to S1 bilaterally
• Right sided posterior and facet arthrodesis with allograft and autograft
• Intraoperative electrical monitoring, intraoperative 3D imaging

Adopt a Stepwise Approach to Coding Each Surgical Step

In the example above, begin by listing all steps that were done and be specific for levels operated in the spine.

Step 1: Look for primary arthrodesis: You report the arthrodesis at L4-L5 and L5-S1 with 22633 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace [other than for decompression], single interspace and segment; lumbar) and 22634 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace [other than for decompression], single interspace and segment; each additional interspace and segment [List separately in addition to code for primary procedure]).

“The combination of a left transforaminal interbody fusion and a right posterior fusion prompts use of the combined posterior and posterior interbody fusion codes (22633, 22634).  These combined fusion codes were developed because of the high frequency with which the two locations of fusion were concurrently performed,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Step 2: Beware of bundles services: These codes describe the work of a combined posterolateral and posterior interbody lumbar fusion. While the scenario additionally describes discectomy and facetectomy at these levels, both are considered bundled services.

“This continues to be an area of confusion among surgeons, coders and payers,” Przybylski says.  “The performance of a transforaminal interbody fusion requires exposure and protection of at least one nerve that is passed to access the disc.  The description of service for 22630-22634 includes laminectomy, facetectomy and discectomy performed in a patient with prior surgery at that level.  Consequently, NCCI edits include numerous discectomy and laminectomy codes.  For example, a recurrent L45 intraforaminal disc herniation which is removed and interbody fusion performed includes the decompression of the intraforaminal L4 nerve root, precluding additional reporting of a decompression code.  In contrast, a patient with L45 spondylolisthesis with bilateral radiculopathy and claudication undergoing a left L45 combined posterior and posterior interbody fusion along with bilateral L45 medial facetectomies for lateral recess decompression of bilateral L5 nerve roots would support separate reporting of CPT^® 63047 for the contralateral L5 nerve root decompression.  The surgeon needs to specify which nerve(s) is/are being decompressed in order to determine whether a separately identifiable decompression is performed.”

Step 3: Don’t forget the decompression: The operative note must describe the additional decompression above and beyond that required to perform the interbody fusion. For this procedure, could you submit code 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar) for L4-5 and code 63048 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]) for L5-S1.

In order to determine if separately identifiable decompression can be reported, you would need more detail regarding the nerve(s) decompressed.  The scenario provided describes unilateral L4-5 and L5-S1 left medial facetectomies on the same side as the performance of the transforaminal interbody fusions.  “Exposure and protection of the left L4 and L5 nerve roots is required to perform the transforaminal approach to the interbody fusion,” Przybylski says. “Therefore, the left L4 and left L5 nerve root exposures are included in CPT^® 22633 22634. However, if the surgeon describes decompression of the left S1 nerve root, then one may separately report CPT^® 63047 appended with the modifier 59.”

Note: You can separately report the decompression by appending the 59 (Distinct procedural service...) modifier to codes 63047. “Modifier 59 modifier is appended to the decompression code to identify the separate site of the decompression from the site of performance of the interbody fusion,” Przybylski says. 

Step 4: Insist on instrumentation: The segmental pedicle screw instrumentation from L4-S1 would be reported as 22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure]). “However, if only L4 and S1 pedicle screw instrumentation was placed (which may occur when anomalies of the L5 pedicle related to spondylolytic spondylolisthesis precludes fixation at L5), one would report 22840 for non-segmental fixation since only two points of fixation are performed,” Przybylski says. 

Step 5: Gather details on grafting: The interbody allograft would be reported with 20931 (Allograft, structural, for spine surgery only [List separately in addition to code for primary procedure]). Since two separate allografts are sized and placed at two separate sites, two units may be reported.

Payers may not recognize multiple reporting of the same bone graft code.  While recognition of different types of bone graft used in the same procedure, one would not typically report multiple units of the same type of bone graft unless harvested from separate site (e.g., bilateral iliac crest grafting).  “Since the structural allograft 20931 describes the work of sizing and preparing the bone for fusion, preparation of separate structural allografts for separate site use warrants reporting CPT^® 20931 a second time with modifier 59. Remember, placement of bone graft is included in the work of arthrodesis.  Therefore, one would not report placement of supplemental cancellous autograft CPT^® 20936 and demineralized bone matrix allograft CPT^® 20930 twice,” Przybylski says.

The placement of demineralized bone matrix would be reported with 20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only [List separately in addition to code for primary procedure]) and the local autograft would be reported with 20936 (Autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinous process, or laminar fragments] obtained from same incision [List separately in addition to code for primary procedure]).

What is inclusive: The intraoperative monitoring would not be separately reportable by the operating surgeon or assistant surgeon. The 3D intraoperative fluoroscopic imaging would not be separately reportable.

“Intraoperative monitoring may not be reported by the operating surgeon, as one cannot work as a surgeon and a neurophysiologist concurrently,” Przybylski says.  “One may report the work of computerized navigation CPT^® 61783 if pre-operative planning is performed with imaging followed by use of intraoperative markers and syncing surgical tools with the navigation software to facilitate anatomical recognition for placement of fixation.”