Neurosurgery Coding Alert

When billing for a posterolateral interbody fusion (PLIF), such as code 22630 (arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) or 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]), there is often confusion regarding whether these codes are inclusive and therefore cannot be billed together.

Coders may also not realize that they can bill for the bone graft as well because the codes do not mention bone graft in their definitions and the neurosurgeon may forget to mention in the operative report that it was performed. By submitting appropriate documentation to show that different sites were addressed, using correct modifiers, and billing for grafts, coders may obtain this additional payment.

Billing 22630 and 22612

The concern regarding billing 22630 and 22612 together for the same surgical session usually begins because the coder wonders if there is a separate posterolateral fusion at the spinal level in question. For example, a neurosurgeon performs a PLIF and diskectomy using iliac crest graft for fusion at L5-S1. The neurosurgeon is doing an L5 discectomy with posterior interbody fusionand pedicle screws with posterolateral fusion of the facet joint of L4-L5. The posterior interbody fusion is considered separate from the posterolateral fusion because it is done at a different part of the vertebral interspace. Further, 22612 does not include the minimal discectomy that 22630 does, which is why it is appropriate to code 22612 with modifier -51 (multiple procedures) to describe the second procedure.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, states that he may include the posterolateral technique with the interbody method if little more than roughing of the lateral facets and minimal grafting is done. In Sandhams experience most of the dissection and decompression is done with the interbody fusion, and the posterolateral fusion is minimal. However, if a structural posterolateral fusion is performed, he will bill 22630 and 22612-51 together and has seen them paid when billed as components because there are no Correct Coding Initiative (CCI) bundles for them.

Billing for Bone Graft and Pedicle Screws

A common coding error is not billing for the bone graft when a neurosurgeon performs an arthrodesis (22630 and 22612), says Ginger Adkins, CPC, account manager for five neurosurgeons at the Neurosurgical Medical Clinic in San Diego. She reports that for a PLIF, 20931 (allograft for spine surgery only; structural) is usually appropriate to use for bone that came from a bone bank, and 20938 (autograft for spine surgery only [includes harvesting the graft]; structural, bicortical or tricortical [through separate skin or fascial incision]) for bone that came from the patients body.

You also need to remember to code for the pedicle screws that are used during this type of surgery to stabilize the spine. For the example listed above where the pedicle fixation is across one interspace (L5-S1), use 22840 (posterior non-segmental instrumentation [e.g., Harrington rod technique], pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation).

Adkins recommends ensuring that the operative report supports the use of all of the above codes to prevent problems with insurance carriers.