Neurosurgery Coding Alert

Clearly define services for decompression and fusion; add codes for grafts and instrumentation.

Coding for cervical spine procedures and fracture reductions can be challenging due to the complexity of the procedures for decompression and fusion. However, these challenges can be dissipated by adopting a stepwise approach to confirm each component of the procedure. Here are examples of operative steps that will help you to deepen your understanding of coding for cervical spine procedures.

Begin With Decompression

When reporting cervical spine procedures, the step for you is to read the operative note and confirm the type of laminectomy or decompression. Also check if the procedure extended to the occiput.  “There are specific codes for addressing decompression and fusion to the occiput,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison

Example: You may confirm the following steps in the operative note:

• Decompression of the C1 ring and removal of the posterior aspect of the C1 ring
• Removal of the superior aspect of the C2 spinous processes and lamina down to the level of the ligamentum flavum using a high speed Stryker drill
• Removal of the occiput about 2.5 cm high and lateral extension with creation of a significant amount of foramen magnum decompression
• Dural expansion with a fascial graft.

Code: When your surgeon performs surgical decompression of the suboccipital area along with the cervical laminectomies of C1 and C2, you should submit code 61343 (Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft [e.g., Arnold-Chiari malformation]).

Count Levels for Fusion

Fusion is a common procedure in the cervical spine. When you report fusion, you need to keep a count of levels at which the fusion was done.

Example 1: The operative note may read the following:

“A midline incision was made from the occipital protuberance down to about the level of C5. This incision was carried down to the midline, down to the lamina. C1, C2, C3, C4 were easily identified as was the occiput. After retractors were put into place, lateral mass screws were put in place into C2, C3, and C4 using imaging guidance. An occipital plate was placed with 4 screws of 66 mm screws affixed to the occiput.”

Codes: For posterior occipitocervical fusion, you submit the following codes:

• Code 22590 (Arthrodesis, posterior technique, craniocervical [occiput-C2]) for fusion from the occiput to level C2,
• Code 22600-51 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment) for C2-C3 fusion, and
• Code +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) for C3-C4 fusion.

Example 2: Your surgeon may document the Gallie technique for cervical fusion. During the Gallie technique, the neurosurgeon uses a sublaminar wire at C1 before he places the graft.

Code: You report the arthrodesis component of a Gallie technique with code 22595.  “Alternatively, the Brook’s technique is also used by some for performing a posterior C1-C2 fusion,” Przybylski says.

Do Not Miss the Graft

Lastly, you should always check if a graft was used to perform the fusion.

Example: You may read in the operative note that the remaining remnants of laminae running from C2 down to C4 were roughed up and an autograft was laid for interlaminar as well as facet fusion.

Code: You report local laminar autograft 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]).

Always Add the Instrumentation Code

In the decompression, reduction, and fusion procedure, use of wires and screws is common. In the examples discussed, the procedure focusses on posterior segmental fixation.

Codes: For posterior segment instrumentation, you turn to code +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]).

You have a specific code for the instrument component of the Gallie technique. For sublaminar wiring at C1, you submit code +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]).  “This is differentiated from interspinous wiring which would be reported with CPT^® 22841,” Przybylski says.

22326 Applies to Cervical Fracture Reduction

Traumatic fractures in the cervical spine need may reduction and/or decompression. Code 22326 (Open treatment and/or reduction of vertebral fracture[s] and/or dislocation[s], posterior approach, 1 fractured vertebra or dislocated segment; cervical) is typically applied to traumatic fracture/dislocations in the cervical spine. This code covers the work involved in bony decompression and manual reduction of a dislocation. “It also includes any decompression performed at that level, so a separate laminectomy code would not be reported,” Przybylski says.