Neurosurgery Coding Alert

Key: Report all procedures and levels to earn full payment.

Spinal procedures can seem complex when you’re not clear about the work your surgeon is doing and at what levels. Once you are sure of these two parameters, you’re on your way to full pay for your spinal claims.

How Would You Code This?

Let the following case study guide your coding. Here’s an overview of the work done:

You may read that your surgeon documented a preoperative and postoperative diagnosis of C3-4, C4-5, C5-6, and C6-7 disk herniations with canal stenosis and neural compression producing bilateral radiculopathy and cervical myelopathy and the following procedures were performed:

1. Gardner-Wells tongs and cervical traction.

2. C3-4, C4-5, C5-6, and C6-7 radical anterior discectomy.

3. C3, C4, C5, C6, C7 partial corpectomy.

4. C3-4, C4-5, C5-6, and C6-7 bilateral anterior foraminotomy.

5. C3-4, C4-5, C5-6, and C6-7 interbody fusions with allograft.

6. Cutting and trimming of allograft.

7. C3, C4, C5, C6, C7 instrumentation using SARAL titanium plate and screws under fluoroscopy.

Op note text: To further illustrate the physician’s documentation for these services, check out the operative note contributed by one of our readers:

"The patient was given general anesthesia and was positioned supine with support under the shoulders. The head was supported on a Mayfield cerebellar headrest with the neck in slight extension. Garner-Wells tongs were applied and 5 pounds traction was established. The neck was shaved and prepared with Betadine soap and paint and the usual drapes were applied. Skin incision was made along the anterior border of the sternomastoid for approximately 3 inches in length and the platysma was divided in line with the skin incision. The dissection was continued between the carotid vessels laterally and the trachea and esophagus medially until the anterior border of the vertebral bodies was reached. The levels were confirmed with an X-ray and the Cloward retractors were applied on either side of C5-C6 disk. The anterior osteophytes were removed and the disk was incised using #1 blade. Radical discectomy was carried out including the cartilaginous endplates."

"A disk space spreader was introduced and the disk space was distracted. Partial corpectomy of the lower end of C5 and upper end of C6 were done by removing the osteophytes and ends of the cortical endplates. The decompression was extended posteriorly and laterally to achieve bilateral anterior foraminotomy. The posterior longitudinal ligament was removed to expose and decompress the dural sac and the nerve roots in the full width of the spinal canal. A 12 mm bone plug was cut up into appropriate length and height and it was inserted into the disk space."

"When the disk space spreader was removed, the bone plug was found to be held tightly in place. The space on either side of the bone plug was packed with bone chips until the entire disk space was filled with bone material. Next, the same procedure was done at C6-C7 level, then at the C3-C4 level and finally at the C4-C5 level. The decompression and fusion were found to be adequate and satisfactory at all 4 levels. An 83-mm SARAL plate was selected and it was applied under fluoroscopy using 16 mm screws, 2 open at C7 and 14 mm screws, 2 at C3, C4, C5, and C6 levels. The plate and screw positions were found to be satisfactory. Hemostasis was achieved and the wound was irrigated with antibiotic saline. The wound was then closed using 3-0 Vicryl for platysma, 3-0 Vicryl for subcutaneous tissue, and 4-0 Vicryl for subcuticular skin closure."

What to Code: Report Arthrodesis at Each Level

For the procedures described in the case study above, you report codes 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2), +22552 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace [List separately in addition to code for separate procedure]) x3 for the anterior interbody arthrodesis. Code 22551 is for level C3-4. You report 3 units of +22552 for C4-5, C5-6, and C6-7. These codes are inclusive of discectomy and decompression.

Do Not Miss the Grafts and Instrumentation

You report codes +20931 (Allograft, structural, for spine surgery only [List separately in addition to code for primary procedure]) and +22846 (Anterior instrumentation; 4 to 7 vertebral segments [List separately in addition to code for primary procedure]) for the allograft and anterior instrumentation.

Important: "The report does not support use of corpectomy codes," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

The bony removal is considered inclusive in 22551. "The cervical corpectomy codes are intended to describe vertebral body removal from one disc space to an adjacent disc space. More than half of the cervical vertebral body must be removed to warrant use of the corpectomy codes. The operative note describes extended discectomies with endplate bone removal for osteophytectomy," says Przybylski.