Neurosurgery Coding Alert

Approach, span and devices influence your claim

When your neurosurgeon provides spinal instrumentation services, you'll need to identify what instruments were used and whether the surgeon removed and reinserted the instrumentation. Brush up on your spinal instrumentation coding skills -- and improve your claim results for these services -- by following our expert advice:

Identify the Device

When your surgeon places wires, screws, rods, or any other spinal fixation, you can efficiently select the appropriate code if you know the approach and fixation points.

There are ten codes you can choose from when you report initial spinal instrumentation:

• + 22840 -- Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxialtransarticular screw fixation, sublaminar wiring at C1, facet screw fixation)[List separately in addition to code for primary procedure]
• +22841 -- Internal spinal fixation by wiring of spinous processes [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]
• +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]
• +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]
• +22845 -- Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to code for primary procedure]
• + 22846 -- Anterior instrumentation; 4 to 7 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]
• +22848 -- Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum [List separately in addition to code for primary procedure]
• +22851 -- Application of intervertebral biomechanical device(s) (e.g., synthetic cage[s], methylmethacrylate) to vertebral defect or interspace. [List separately in addition to code for primary procedure]

Determine the Approach

You'll be well on the way to appropriate coding if you can determine from the op note whether the neurosurgeon used an anterior or posterior approach for the instrumentation.

You select from codes 22840, 22841, 22842, 22843, 22844 and 22848 for a posterior approach and 22845, 22846, and22847 for an anterior approach for the spinal instrumentation. 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.

Don't miss: "An intervertebral biomechanical device, reported with 22851, can be placed either through an anterior or posterior approach. Code 22848 is used to describe pelvic fixation separate from sacral fixation, and is typically used in addition to a posterior segmental fixation code," advises Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Count Fixation Points in Posterior Approach

Once you confirm the posterior approach, the next step is to determine if the device is segmental (22842-22844) or non-segmental (22840). For this portion, you count the number of fixation points.

Irrespective of the span, if the instrumentation is attached to only two vertebral segments, you consider the instrumentation to be non-segmental and report code 22840. If, however, the instrumentation is affixed to three or more vertebral segments, the instrumentation is considered segmental. "Although spine surgeons apply the biomechanical definition of segmental fixation to L4-5 pedicle screw fixation, CPT® defines this as non-segmental fixation since instrumentation only attaches to two segments," says Przybylski.

"In order for instrumentation to be considered segmental, there must be a proximal fixation point and a distal fixation point 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.

Confirm Removal of Vertebral Portions

Your surgeon may remove a vertebra (i.e. corpectomy) or may remove an intervertebral disc. If the surgeon uses a metal cage or other prosthetic device to fill the defect in order to stabilize the area, you specifically report this as code 22851.

Remember: When reporting 22851, you count the number of spinal defects treated, not the number of devices placed within a single defect. If the surgeon uses multiple devices at one defect, you report only a single unit of 22851. If, however, the surgeon places devices at more than one spinal defect, you report one unit of 22851 for each individual spinal defect treated. The additional units would be appended with modifier -59(Distinct procedural service) to signify the separate anatomical sites.

Example: If your surgeon places two cages at T4-T5, you report one unit of 22851. However, if your surgeon places one cage at T3-T4 and two cages at level T5-T6, you report 22851 and 22851-59.

Distinguish Instrumentation Removal

There are different codes you may choose from when your surgeon is removing spinal instrumentation. You can report the instrumentation removal if the surgeon removes the instrumentation for damage, failure or other complications. If, however, the surgeon does the removal to explore the spinal fusion, you cannot report the instrumentation removal in addition to the exploration of fusion.

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

• 22850 -- Removal of posterior nonsegmental instrumentation (e.g., Harrington rod)
• 22852 -- Removal of posterior segmental instrumentation
• 22855 -- Removal of anterior instrumentation.

Furthermore: Note that the instrumentation codes are stand-alone codes and are subject to the -51 multiple procedure modifier reduction. In addition, code 22855 can be shared among co-surgeons, such as when an approach surgeon exposes the anterior thoracolumbar spine so that the spine surgeon can safely remove anterior spinal instrumentation.

Report Reinsertions

Your surgeon in some instances like a revision of a prior fusion for pseudoarthrosis may reinsert the instrumentation after the procedure is complete; in this case, you would report 22849(Reinsertion of spinal fixation device). This instrumentation code is also a stand-alone code subject to the -51 multiple procedure modifier reduction.

Be Careful with Modifiers

Confirm with your payer which modifiers are approved for spinal instrumentation services, as not all may be accepted. Some will permit modifier -59(Distinct procedural service) to the 'additional' unit(s) to demonstrate that the surgeon did the instrumentation at separate anatomic location(s). "Since most of the instrumentation codes are add-on codes, those are most subject to the -51 modifier. Both the anterior instrumentation removal 22855 and revision of instrumentation code 22849both accept the -62 co-surgery modifier," says Przybylski.

Example: If your surgeon places one cage at T3-T4 and two cages at level T5-T6, you report 22851 x 2 and append modifier -59depending upon your payer. "In this scenario, CPT® advises reporting the cages placed at different spinal interspaces as two line items, 22851 and 22851-59," says Stout.

Spinal instrumentation codes (22840-22848 and 22851) are modifier -51 (Multiple procedures) exempt, so you would not report -51 with any of these. Carefully study the operative note to determine where the surgeon places the instrumentation

Example: If you read that the surgeon performed arthrodesis at interspaces C6-7, C7-T1 and T1-T2 and placed anterior instrumentation attached at C6 and T2, you report 22846 for the instrumentation for the four segments C6 to T2. "You also report the appropriate codes for arthrodesis for each level. These are 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2) and +22585 (... each additional interspace [list separately in addition to code for primary procedure]) for C7-T1 and T1-T2 interspaces. Code

22554 applies as the initial level arthrodesis since the surgical approach in this circumstance would be an extended anterior cervical approach," says Przybylski. "When an arthrodesis crosses spinal regions (in this case from cervical to thoracic), only one primary arthrodesis code can be reported. In this case, you would report 22554 and +22585, +22585-59. Also report the code for the type of interbody device and/or graft material that was used. If a separate anterior plate is applied from C6 to T2, report code 22846," says Stout.

When your surgeon is removing the instrumentation in the global period because an infection necessitated the return of the patient to the operating room for the removal, you append modifier -78 (Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period) to the appropriate spinal instrumentation removal code. "Codes for spinal instrumentation removal are 22855, 22850, and 22852," says Stout.