Neurosurgery Coding Alert

Reporting graft procedures can be complicated for several reasons. Coders must know how to distinguish among the various types of grafts and locate the appropriate codes in CPT. In addition, graft procedures are often but not consistently included in the more comprehensive surgical procedure performed at the same time as the graft. Finally, modifiers are sometimes needed if payers are to recognize and reimburse graft codes appropriately. Know Your Grafts Depending on the "material" needed, surgeons may graft virtually any human tissue, including bone, cartilage, tendon, skin, fat or nerves. When you report graft procedures, the material harvested, as well as the location of the graft, must coincide with the code. And, bone grafts (for spinal repair/reconstruction, for instance) may be obtained by an autograft or allograft. An autograft is taken from a patient for transplantation elsewhere on the same patient's body (e.g., bone is taken from a rib to complete a spinal fusion). In this case, the operating surgeon harvests and places the graft. An allograft is a bone graft between members of the same species. The graft is harvested from a cadaver or living donor, frozen or freeze-dried, and kept in a surgical or regional bone bank until needed. The operating surgeon does not harvest the allograft but obtains it from the bone bank prior to surgery. Bone grafts may further be described as structural or morselized. A structural bone graft consists of a single piece of bone that provides direct support for skeletal structures, while a morselized (or small-segment) graft consists of small pieces of bone joined together to fill bony cavities, primarily to promote new bone growth. For example, following posterior cervical laminectomy and instrumentation, morselized bone is placed in open areas on either side of the spine and in the interspinal spaces. The morselized graft may be obtained from a bone bank or prepared by the surgeon in the operating room using bone provided by the bone bank. Spinal Procedures Codes 20930-20938 describe bone grafts for spinal repair/reconstruction: 20930 Allograft for spine surgery only; morselized 20931 structural 20936 Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision 20937 morselized (through separate skin or fascial incision) 20938 structural, bicortical or tricortical (through separate skin or fascial incision).

Codes 20930 and 20931 describe only placement of the graft, while 20936-20938 include placement and harvesting. If the graft is taken from the same skin and fascial incision as that used to access the spine for repair, 20936 is appropriate (occasionally an iliac bone graft is harvested through a separate fascial incision during lumbar surgery). If a separate skin or fascial incision is necessary to obtain the graft, [...]