Neurosurgery Coding Alert

Similarities among vertebral corpectomy, anterior discectomy, partial excision of vertebrae, and osteotomy of spine make choosing among these codes a real challenge. If a difficult operative report overwhelms you, slow down and identify the component steps that distinguish each procedure.

Your most effective tool to distinguish among spinal procedures is a firm grasp of what each code set includes.

For example, anterior vertebral corpectomy, also sometimes called vertebral body resection, involves total or near-total removal of the vertebral body. All vertebral corpectomy procedures include discectomy and can occur either with spinal canal decompression (63081-63091) or with excision of an intraspinal lesion (63300-63308), the latter of which involves decompression of the spinal cord and/or nerve root(s), says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

When reporting vertebral corpectomy with decompression (63081-63091), you should not report fracture care -- which is common with procedures of this type -- separately. You may, however, separately bill for arthrodesis (22548-22812, to stabilize the spine) and spinal reconstruction procedures, including bone grafts (20930-20938) and spinal instrumentation (22840-22855).

Example: To treat a compressed nerve caused by fracture, the surgeon performs discectomies followed by corpectomy of segments C4 and C5. She frees compressed nerve roots and reconstructs the spine using a tricortical allograft and titanium plates.

Although the surgeon removes only two vertebral bodies, the arthrodesis occurs across three interspaces. The instrumentation involves four segments because the fixation will extend above and below the two reconstructed segments.

In this case, you would report:

When the surgeon performs corpectomy for an intraspinal lesion -- either with or without decompression (63300-63308) -- you will select a final code according to location (cervical, thoracic, or lumbar or sacral), approach (anterior or anterolateral, transthoracic, thoracolumbar, or transperitoneal or retroperitoneal) and whether the surgeon cuts into the dura (intradural) or not (extradural). In these cases, the surgeon removes the bone not as an end in itself but as a necessary step to access and remove an intraspinal lesion(s), Przybylski says.

Example: Via anterior approach, the surgeon accesses segments C4 and C5, opening the dura and exposing the tumor for excision. In this case, you would report the primary procedure using 63304 (Vertebral corpectomy [vertebral body resection], partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical) for the first segment (C4) and +63308 (... each additional segment [list separately in addition to codes for single segment]).

If the operative report describes decompression with removal of intervertebral discs and osteophytes (or bone growths) only, you should reach for the anterior discectomy codes (63075-63078). Because the vertebral body remains intact, these procedures are somewhat less extensive than either 63081-63091 or 63300-63308.

Osteophytectomy codes 63075 and 63077 specify "single interspace" (that is, one space between two vertebrae), so your code selection should reflect the specific interspace treated.

Example: Taking an anterior approach and using the operating microscope, the surgeon performs anterior discectomy that extends to include the posterior osteophytes at the T5-T6, T6-T7 and T7-T8 interspaces. You should report the surgery as 63077, 63078 x 2 (according to CPT, use of an operating microscope [69990] is included in 63075-63078).

Special consideration: If the surgeon performs an anterior lumbar discectomy (for which there is no specific code), report 64999 (Unlisted procedure, nervous system).

Alternatively, some insurers may accept 63077 with modifier 22 (Increased procedural services) appended. Specify "lumbar, not thoracic" in the "Comments" portion of the claim form. Przybylski says, however, that this practice does not follow CPT rules for using 63077. Therefore, check with your individual payer for guidelines, and ask for its acceptance in writing.

You can identify partial excisions (22100-22103) easily if you remember that these are strictly "bony" procedures that do not include decompression or discectomy. Additionally, these codes apply when the surgeon removes only a posterior component (for instance, the spinous process), rather than the body of the vertebrae.

Codes 22110-22116, meanwhile, are very similar to corpectomy procedures 63300-63308. In both procedures, the surgeon may remove a portion of the vertebral body without decompression of the spinal cord or nerve roots. When performing 22110-22116, however, the surgeon removes a portion of the vertebra to excise an intrinsic bony lesion rather than to gain access to the nerves or spinal canal.

Like partial excisions, osteotomy (22210-22226) also describes removal of a portion of vertebral segments. These procedures generally do not include decompression (in contrast to 63081-63091) and involve more extensive bone work than 63075-63078. Osteotomy code subset 22220-22226 also includes discectomy. The purpose of these procedures is not to release pressure from the spinal cord or nerve roots or remove a bony lesion but to correct a spinal deformity.

You should choose the proper code by location and approach. For posterior or posterolateral approach to a cervical segment, for instance, you would select 22210 (Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; cervical).