Neurosurgery Coding Alert

CPT 2008 will bring relatively few changes directed specifically at neurosurgery practice, but among them are three exciting new codes for spinal osteotomy procedures.

These new osteotomy codes include:

A parenthetical reference accompanying the codes in CPT specifies that you-ll use these codes for "pedicle/vertebral body subtraction" -- which surgeons may also refer to as "transpedicular three-column osteotomy."

As outlined in the code descriptors, 22206-22208 all include either posterior or posterolateral approach and involve three columns (the lamina with pedicles/facets, the posterior vertebral body, and the anterior vertebral body) within one vertebral segment. Previously, CPT did not contain a code to describe these procedures. Although these procedures are not commonly done, surgeons and coders really needed a method to account for these complex and lengthy procedures.

Surgeons perform osteotomy of this type most commonly to treat fixed sagittal imbalance (also known as "flat back"), which is itself often related to previous spinal surgery or severe degenerative disc disease with loss of lordosis.-Spinal deformity with straightening or kyphosis causes the patient to lean forward, with the center of gravity in front of the sacrum, resulting in poor posture, pain, difficulty walking and other problems.

Essentially, pedicle/vertebral body subtraction removes posterior bone to increase the forward curvature of the mid-spine (lordosis), so people who are normally hunched over can stand up straighter, says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery. "This is also what differentiates pedicle/vertebral body subtraction from the other posterior spinal osteotomy codes," he adds.

How you-ll use the codes: Most neurosurgery coders will find the format of 22206-22208 familiar and easy to apply. For the first vertebral segment the surgeon treats via either posterior or posterolateral approach for osteotomy of the spine in the thoracic region, you-ll report 22206. Similarly, for the first vertebral segment the surgeon treats via either posterior or posterolateral approach for osteotomy of the spine in the lumbar region, you-ll report 22207. The nature of the surgery precludes the surgeon from treating the cervical spine, which is why there is no such code, Sandhusen says.

You-ll report only a single unit of either 22206 or 22207 per operative session. For each segment the surgeon treats beyond the first, whether thoracic or lumbar, you-ll report one unit of 22208. Because 22208 is an add-on code, you would never report it alone, but only with 22206 or 22207.

Example: The surgeon performs spinal osteotomy using posterior approach to treat fixed sagittal imbalance at levels (segments) T11, T12 and L1. In this case, you should report 22206 for the initial level (T11), and 22208 x 2 for the two additional levels (T12 and L1). Because 22208 is a designated add-on code, there is no need to add modifiers.

Another series of CPT 2008 changes, which consist of added language in the descriptors for spinal grafting and instrumentation procedures, is more bark than bite. The changes have been made to further clarify proper application of these codes. So, if you were reporting the codes correctly in 2007, you-ll have nothing to worry about in 2008, says Jennifer Schmutz, CPC, with Neurosurgical Associates LLC in Salt Lake City.

"This revised and added text in the 2008 book won't really change anything," Schmutz says.

Specifically, CPT has added the phrase "List separately in addition to code for primary procedure" to all spinal graft codes (20930-20938) and to all spinal instrumentation procedure codes (22840-22848 and 22851).

By making these codes designated add-on procedures, CPT reminds coders that you cannot report these codes without a definitive procedure (such as laminectomy 63047-63048, for example). Plus, the additional language clarifies for payers the procedures- status as "modifier 51 exempt" (and therefore not subject to multiple-procedure reductions beyond those already calculated into the procedures- values).

"With the revised text in the 2008 CPT book, these codes are now clearly defined as add-on codes with the designated primary procedure codes clearly listed. Whereas before, it may have not been as clear," Schmutz says.

"The 2008 revisions also cut down on confusion when trying to determine which spinal instrumentation codes may be reported as the primary procedure," she adds.

More information on the way: For complete instructions on reporting spinal instrumentation procedures, look to the next issue (Vol. 9, No. 1) of Neurosurgery Coding Alert.