Neurosurgery Coding Alert

Hint: Verify location, determine span, and append modifiers.

If coding spinal instrumentation has you reaching for pain relievers, you can de-stress by determining the location (anterior or posterior), the span, and the attachment points (segmental or non-segmental) of the instrumentation. Follow these spinal instrumentation best practices from our experts.

1. Verify the Location

You need to determine from the op note whether your surgeon performed anterior or posterior instrumentation. If this isn’t clear, check with your surgeon. “Documenting the approach (anterior, posterior, direct lateral, extreme lateral) is something that spine surgeons do almost unfailingly,” says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

Anterior instrumentation: You select from codes +22845 (Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to code for primary procedure]) - +22847 (Anterior instrumentation; 8 or more vertebral segments [List separately in addition to code for primary procedure]).

Posterior instrumentation: You’ll select from the following options:

+22840 (Posterior non-segmental instrumentation [e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation] [List separately in addition to code for primary procedure])

+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]) - +22844 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 13 or more vertebral segments [List separately in addition to code for primary procedure]).

2.  Count the Levels

Once you have confirmed the location of the instrumentation, the next step for you is to count at how many levels your surgeon did the instrumentation. “You simply count the number of vertebral bones from the most rostral (closest to the head) attachment point to the most caudal (closest to the tailbone) that are spanned by the instrumentation.  It is important to note that fixation is not required at each bone within the span,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Anatomy note: The spinal column is divided into cervical, thoracic, lumber, and sacral segments. There are seven cervical vertebrae, 12 thoracic vertebrae and five lumbar vertebrae. The sacrum is a single bone with five fused sacral segments.

Don’t miss: When you see the descriptors of codes for anterior and posterior instrumentation, you will see the terms ‘segmental’ and ‘non-segmental,’ which is only applied to posterior instrumentation. The instrumentation is said to be non-segmental when your surgeon attaches the device to only two vertebrae in the spine, regardless of the actual span. The instrumentation is segmental if your surgeon attaches the device to at least three points on three different vertebrae. Again, this is regardless of the number of vertebrae spanned.

For posterior instrumentation, you report code +22842 for segmental instrumentation of 3 to 6 vertebrae, +22843 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 7 to 12 vertebral segments [List separately in addition to code for primary procedure]) for instrumentation of 7 to 12 vertebrae, and +22844 for that in 13 or more vertebrae. You also have code +22840 for posterior non-segmental instrumentation across one or more interspaces, provided that only two attachment points exist on distinct segments.

Similarly, for anterior instrumentation, you report codes +22845 (Anterior instrumentation, 2 to 3 segments…), +22846 (Anterior instrumentation; 4 to 7 vertebral segments [List separately in addition to code for primary procedure]), or +22847 depending upon whether your surgeon instrumentation in 2 to 3, 4 to 7, or 8 or more vertebrae, respectively.

Key: “In order for instrumentation to be considered segmental, there must be proximal and distal fixation points with at least one intervening fixation point,” confirms Stout. “A pedicle screw construct that runs from L2 to S1 with screws placed at all intervening levels constitutes 5 segment instrumentation and is reported with code 22842. On the other hand, if a rod and screw construct spans L2 to S1 but no screws are placed at any intervening level, this is non-segmental fixation and is reported with code 22840,” she adds.

3. Don’t Forget the Primary Procedure

The codes for spinal instrumentation are not standalone codes. Instrumentation is inherently an additional procedure in spinal surgeries. Always make sure you are reporting the primary procedure when you report instrumentation.

“Several years ago, CPT^® changed the designation of instrumentation codes from 51 modifier exempt to add-on codes (which are also 51 modifier exempt).  The difference between the designations required identification of all the primary arthrodesis and decompression codes that spinal instrumentation can be “add-on” to,” says Przybylski.

Example: You may read that your surgeon did a ‘bilateral hemilaminectomy with diskectomy and foraminotomy for nerve decompression.’ You may further read that he also performed a ‘lumbar decompression with posterior lumbar interbody fusion and posterior lateral transverse fusion with pedicular screws.’

In this case, because discectomy is an inherent part of posterior interbody arthrodesis, you would not report 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar).

What to report: For your primary procedure, you would report the combined code 22633, since you are performing both a posterior interbody arthrodesis and a posterolateral arthrodesis.  You would not separately report the posterior lumbar interbody fusion, in which a laminectomy, facetectomy and discectomy are performed with decortications of the vertebral endplates and insertion of graft material between them. So, you do not report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar) for posterior interbody technique and 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) for posterior lateral transverse fusion. The combined code was created in 2012 to reflect performing both procedures as the same interspace.

Finally, you also should report the instrumentation. If the neurosurgeon performed a single-level instrumentation (i.e., two adjacent vertebrae), you report 22840. If he performed a two-level (i.e., three-segment) instrumentation attached at L4, L5 and S1, you turn to 22842.

If he implanted the pedicle screws and attached the instrumentation at only two places, 22840 would be correct regardless of how many levels there are between the endpoints. “Typically, a single interspace combined posterior lumbar interbody and posterolateral arthrodesis would be associated with non-segmental instrumentation,” says Przybylski.

4. Report Removal and Reinsertion

You may report instrumentation removal in the event of damage, rejection, or removal done to adjust the instrumentation.

Exception: Remember that you do not report removal of instrumentation when your surgeon does the removal to explore the spinal fusion. “Since it is necessary to remove spinal instrumentation in order to examine a fusion bed for successful arthrodesis including observation for movement, instrumentation removal is considered a bundled service,” says Przybylski. “In an exception, remember that you do not report removal of instrumentation when your surgeon reinserts instrumentation, even if a new set if implants is placed.”

You select from the following codes when reporting the instrumentation removal:

22850 — Removal of posterior non-segmental instrumentation (e.g., Harrington rod)

22852 — Removal of posterior segmental
instrumentation

22855 — Removal of anterior instrumentation.

You report reinsertion with 22849 (Reinsertion of spinal fixation device) when your surgeon removes and the reinserts the instrumentation, such as when there is an implant failure or loosening.

Hint: “The anterior removal of instrumentation code 22855, the reinsertion of instrumentation code 22849, and the posterior removal of instrumentation  codes 22850 and 22852 are stand-alone codes that have 90-day global periods and are subject to the 51 modifier,” says Przybylski.

5. Manage the Modifiers

According to CPT^®, spinal instrumentation procedures are essentially bilateral. Therefore, you should never append modifier 50 (Bilateral procedures) to the anterior or posterior instrumentation codes. 

You should also never append modifier 51 (Multiple procedures) to the instrumentation codes with the exception of the 90 day global codes listed above.

When modifiers would apply: Spinal instrumentation is an additional yet independent procedure and you always look for the primary procedure. “There may be circumstances in which the 59 modifier is applied to instrumentation codes,” says Przybylski. “For example, if interbody prosthetic devices are placed at separate defects, 22851 would be reported twice, the second with the 59 modifier.” You can however make a logical use of modifiers 78 (Return to the operating room for a related procedure during the postoperative period) or 79 (Unrelated procedure or service by the same physician during the postoperative period) if applicable.

If you read that your surgeon performed an unrelated procedure during the global period of a previous fusion/instrumentation, you append modifier 79 to the appropriate procedure code(s). “One would expect a separate diagnostic code(s) for the underlying medical condition(s) if the procedure is truly unrelated,” says Przybylski.

Example 1: If your surgeon performed an anterior cervical fusion during the global period of a lumbar fusion/instrumentation, you report code 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace ([other than for decompression]; cervical below C2) -79.

For a related procedure during the global period, you append modifier 78.

Example 2: When your surgeon returns the patient to the OR during the global period for removal of a previously placed instrumentation after the device failed, you append modifier 78. Thus, you report 22850-78 for the removal of posterior non-segmental instrumentation done in the global period. “In this example, the subsequent procedure is clearly related to the original procedure. Even if you use a new diagnostic code for implant failure, the 78 modifier would still apply,” says Przybylski.