Neurosurgery Coding Alert

If surgeon instruments 3 or more segments, you should report segmental pedicle screw fixation.

When your neurosurgeon performs a posterior lumbar interbody fusion (PLIF), he accesses the patient’s vertebrae through an incision in the patient’s back. The surgeon completes the PLIF by inserting a bone graft or a biomechanical spacer implant to promote fusion between the vertebrae, and he may also insert instrumentation to further stabilize the patient’s spine.

If you don’t know the appropriate add-on codes to report for the bone grafts, interbody prosthetic devices, and pedicle screws the surgeon inserts, you could risk lowering your reimbursement.

Read on to learn everything you need to know to submit clean PLIF claims in your practice.

Observe Rules for Reporting 22630 and +22632

For a standard PLIF procedure, because of the surgeon’s posterior approach, you should report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar).

Code +22632: Code +22632 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)) is an add-on code you report in conjunction with 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)); 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar) or 22633 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar) when performed at a different level, according to CPT^®.

Remember: Follow these tips to keep the add-on codes straight, per the CPT^® guidelines:

• Tip 1: When the surgeon performs a posterior interbody fusion arthrodesis at an additional level without concurrent posterolateral fusion, report +22632.
• Tip 2: When the surgeon performs a posterior or posterolateral technique for fusion/arthrodesis at an additional level, report +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)).
• Tip 3: When the surgeon performs a combined posterior or posterolateral technique with posterior interbody arthrodesis at an additional level report +22634 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)). You should report +22634 in conjunction with code 22633.

Caution: You should never report 22630 in conjunction with 22612 for the same interspace and segment, according to CPT^®.

“Even if performed at different levels, you should report 22630 for the level where the interbody fusion is performed; whereas you should report +22614 for the level where the posterolateral fusion is performed,” explains Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

Example: The neurosurgeon performs a PLIF with a discectomy. He uses a structural iliac crest autograft for fusion at L4/L5 and L5/S1 interspaces. You should report 22630 for the L4/L5 interspace and +22632 for the additional L5/S1 interspace. If only a posterolateral fusion is performed at L5S1, then report +22614 for the additional L5/S1 posterolateral fusion.

Separately Report Bone Grafts, Interbody Prosthetic Devices

If you’re reporting codes 22630 and +22632 for arthrodesis, you can also report the bone grafts the surgeon placed to stabilize the patient’s spine.

Bone grafts: You have the following options for allografts:

• +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure))
• +20931 (Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)) for the allograft.

Autografts: You can turn to +20936 (Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure))-+20938 (… structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)) for autografts.

Don’t miss: You should never append modifier 62 (Two surgeons) to bone graft codes +20930-+20938.

Interbody prosthetic devices: “Code +22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)) is an add-on code that represents the additional work for insertion of a biomechanical device, according to CPT^® Assistant.”

You should report +22853 when the surgeon places an interbody biomechanical device into a discectomy defect for purposes of a spinal fusion, such as a PLIF procedure or an anterior cervical discectomy and fusion (ACDF) procedure, per CPT^® Assistant.

Verify Type of Instrumentation, Number of Segments

Once you verify the type of  instrumentation and number of segments the surgeon used, you can choose from the following codes:

• +22840 (Posterior non-segmental instrumentation (eg, 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)). The CPT^® guidelines define non-segmental instrumentation as “fixation at each end of the construct and may span several vertebral segments without attachment to the intervening segments.”
• +22841 (Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure))
• +22842 (Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)). If the surgeon instruments three or more segments, you should report segmental pedicle screw fixation — code +22842 (Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)), Przybylski says.
• +22843 (… 7 to 12 vertebral segments (List separately in addition to code for primary procedure))
• +22844 (.... 13 or more vertebral segments (List separately in addition to code for primary procedure)).

Caution: You report the insertion of spinal instrumentation separately and in addition to the primary code for the arthrodesis. You should never append modifier 62 to spinal instrumentation codes +22840-+22848; 22850; 22852; 22853; 22854; and 22859, according to the CPT^® guidelines.