Neurosurgery Coding Alert

Good news:  You can report instrumentation removal during repeat fusions

A surgeon performs both posterior and anterior arthrodesis, but the insurer denies 22554 and bundles it into 22600 - so you write off approximately $675 that Medicare allots for 22554 under the multiple procedure rule, right? Not so fast. You've just fallen prey to one of the top three spine coding myths.

The following spine coding scenarios will help you tighten up your claims and give your appeals some muscle. Myth #1: You can't bill instrumentation removal during repeat fusions. Suppose your surgeon places segmental instrumentation during a spinal fusion, but a year later the patient returns complaining of severe low back pain, and the surgeon suspects pseudarthrosis. The surgeon returns the patient to the operating room (OR), removes the instrumentation, and explores the fusion mass (22830, Exploration of spinal fusion). The surgeon confirms pseudarthrosis and performs a redo fusion.

"Some Medicare carriers say you can't use the instrumentation removal codes with 22830," said Greg Przybylski, MD, professor and director of neurosurgery at the NJ Neuroscience Institute at JFK Medical Center and Seton Hall University, at the May Coding Institute audioconference, "8 Stellar Strategies for Spine Surgery Pay-up." Those Medicare payers are wrong, Przybylski says. "CPT added language in 2005 that states the AMA's position, which is that you can use the instrumentation removal/reinsertion codes with 22830."

The applicable removal/reinsertion codes you should report are:
  22849 - Reinsertion of spinal fixation device
  22850 - Removal of posterior nonsegmental instrumentation (eg,Harrington rod)
  22852 - Removal of posterior segmental instrumentation
  22855 - Removal of anterior instrumentation Justification: CPT states, "Report modifier 51 (Multiple procedures) with 22849, 22850, 22852 and 22855 when instrumentation reinsertion or removal is reported with ... definitive procedures such as arthrodesis, decompression, and exploration of fusion."

Possible roadblock: The National Correct Coding Initiative has not caught up with this CPT revision, and still bundles 22830 into 22850, 22852 and 22855. If your insurer continues to deny your instrumentation removal claims when you report spinal fusion, copy the applicable page of CPT (the notation is printed directly above code 22830's descriptor), and send it with your appeal, along with a short letter from the surgeon. Myth #2: You can bill corpectomy with lumbar interbody fusion. Your spine surgeon turns in this operative note:

"I performed a transforaminal lumbar interbody fusion at L4-5, and performed osteotomy anteriorly in the disc space to augment the fusion and posteriorly to facilitate placement of the cages. I prepared the end plates and packed autograft bone anteriorly and laterally, then placed 9x22mm cages packed with cancellous autograft."

Your surgeon recommends that you report the arthrodesis code along with a partial corpectomy (63087, Vertebral corpectomy [vertebral body resection], partial or complete, combined [...]