Neurosurgery Coding Alert

Key: Don't overlook the chance to report bone grafts.

When your neurosurgeon performs posterior lumbar interbody fusion (PLIF), take special care to review the documentation for details on instrumentation placement and notes on other procedures performed at the same time. If you miss these separate services, you risk lowering your reimbursement.

Whether you can report laminectomy separately, however, depends on the extent of the surgeon's effort.

1. Turn to 22632 for Additional Interspaces

For a standard PLIF procedure, you should report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar).

If the surgeon treats additional interspaces beyond the first, you should report +22632 (... each additional interspace [list separately in addition to code for primary procedure]) for each additional interspace.

For example, the neurosurgeon performs PLIF with diskectomy, using a structural iliac crest autograft for fusion at L4/L5 and L5/S1 interspaces. In this case, you should report 22630 (for the L4/L5 interspace) and 22632 (for the additional L5/S1 interspace).

Reimbursement tip: Payers should not apply a multiple-procedure reduction to the "additional interspace" code (22632). Add-on procedures are multiple-procedure exempt, according to CPT guidelines. Make sure you review the EOB (explanation of benefits) to confirm that inappropriate reductions were not taken by the payer.

2. Keep Bone Grafts, Interbody Devices, and Pedicle Screws Separate

If you're reporting arthrodesis (22630 and 22632), don't forget about bone grafts that the surgeon places to stabilize the spine.

Generally, surgeons will use either an allograft (20931, Allograft for spine surgery only; structural), which describes bone that comes from a bone bank, or an autograft (20938, Autograft for spine surgery only [includes harvesting the graft]; structural, bicortical or tricortical [through separate skin or fascial incision]), in which the bone comes from the patient's own body.

"Concern about the separate site incision with risks of postoperative infection and pain have led many surgeons to choose structural allograft over autograft options," observes Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Some surgeons also use an interbody prosthetic device (22851, Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace [List separately in addition to code for primary procedure]), adds Przybylski. "This code does not apply to machined bone, which should be reported as 20931," he advises. "Code 22851 should be reported once per interspace, regardless of the number of prosthetic devices placed within one interspace. If more than one interspace receives a prosthetic device, code 22851 may be reported again for each interspace appended with the -59 modifier. With revision to code 22851, threaded bone allograft is now reported with 20931 rather than 22851."

Depending on circumstances, however, surgeons can choose any procedure from the 20930-20938 series for bone grafts.

For instance: In the above example, the surgeon used an autograft to complete the fusion. Therefore, you would report 20938 in addition to 22630/22632 for the arthrodesis.

And you should account for pedicle screw fixation (22840, Posterior nonsegmental instrumentation [e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation]), if used, for a single level. If three or more segments are instrumented, you should account for segmental pedicle screw fixation (22842), Przybylski advises. Again, payers should not apply multiple-procedure reductions to instrumentation procedures.

3. Bundle 'Standard' Laminectomy

Because laminectomy is a standard component of arthrodesis necessary to access and prepare the interspace for surgery, you should not regularly report 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) in addition to 22630/22632, according to CPT Assistant, December 1999 and January 2001.

However, you may separately report arthrodesis and laminectomy in some circumstances, according to CPT Assistant. Specifically, the January 2001 CPT Assistant states that you should report 63045-63048, as appropriate, "when in addition to removing the disk and preparing the vertebral endplate, the surgeon removes posterior osteophytes and decompresses the spinal cord or nerve root(s), which requires work in excess of that normally performed when doing a posterior lumbar interbody fusion (PLIF)."

For example: The surgeon prepares the L1/L2 interspace for arthrodesis. And he extends the laminectomy outward to decompress the nerve root by performing a foraminotomy, and removes excess bone.

In this case, you should report 22630 for the arthrodesis and 63047 appended with modifier 59 for the "extended" laminectomy, and you may report any bone graft or instrumentation procedures the surgeon performs at the same time.