Neurosurgery Coding Alert

Clinical similarities make it difficult to distinguish an anterior vertebral corpectomy (63081-63091) from an anterior diskectomy (63075-63078), partial excision (22100-22103 and 22110-22116) or osteotomy of spine (22210-22226). All of these spinal surgeries involve removal of bone and/or vertebral disks, and the differences between them must be understood to ensure accurate coding. Also, other procedures such
as arthrodesis and spinal instrumentation may be performed at the same time and may be separately billable.

 
Anterior vertebral corpectomy, or vertebral body resection, involves partial or complete removal of the vertebral body. Codes 63081-63091 specify with decompression of spinal cord and/or nerve root(s). They are appropriately reported, according to CPT Coding Made Easy: A Technical Guide, to correct a compressed spinal cord caused by "trauma to a vertebra (such as a fracture), collapse of a vertebra due to bone cancer (degeneration of bone) or other reasons ... " These procedures include diskectomy above and/or below the vertebral body or bodies removed.
 
Also, if a spinal fracture is repaired, the vertebral corpectomy is the definitive treatment. The fracture-care codes may not be reported in addition to 63081-63091. However, arthrodesis (22548-22812, to stabilize the spine) and spinal reconstruction, including bone grafts (20930-20938) and spinal instrumentation (22840-22855), are separately payable. Also, bone-graft and instrumentation codes, although not specifically defined as add-on procedures, "are reported in addition to codes for the definitive procedure(s)" and should not be appended with modifier -51 (multiple procedures), according to CPT. An operating microscope (69990) may be used during these procedures and may be billed for some non-Medicare payers. Code 69990 is an add-on procedure not subject to multiple-procedure reductions.
 
The appropriate code is selected by location (63081, cervical; 63085, thoracic; 63087, lower thoracic or lumbar; or 63090 lower thoracic, lumbar, or sacral). Report the primary-procedure code for the first vertebral segment removed. If additional segments are removed, "list removal of the second and any subsequent vertebral bodies using the appropriate code(s) for 'each additional segment,' " according to CPT Coding Made Easy. The add-on codes -- 63076, 63078, 63082, 63086, 63088 and 63091 -- for each additional segment should be reimbursed at their full value.
 
For example, to treat a compressed nerve of the spine caused by fracture, diskectomies are performed with the aid of an operating microscope, followed by corpectomy of segments C3 and C4. Compressed nerve roots are freed and the site is prepared for spinal reconstruction, which is accomplished using tricortical allograft and titanium plates. The wound is closed using sutured layers. Report the session as follows, listing the primary procedure and its associated add-on codes first:

63081

63082

22554 -- arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); cervical below C2
 

22585 x 2 -- ... each additional interspace (list separately in addition to code for primary procedure)
 

20931 -- allograft for spine surgery only; structural
 

22846 -- anterior instrumentation; 4 to 7 vertebral segments

 
Although only two vertebral bodies are removed, the arthrodesis occurs across three interspaces. Add-on code 22585, for the additional interspaces, should be reimbursed at its full value. And the instrumentation will involve four segments because the fixation will extend above and below the two reconstructed segments.
 
Note: If your carrier requires modifier -51 to report multiple procedures, attach this modifier to the arthrodesis code, 22554. Ask your carriers for their guidelines.

Reporting Corpectomy Without Decompression

 
Corpectomy codes 63300-63308 (excision, anterior or anterolateral approach, intraspinal lesion) do not involve decompression. These procedures are performed for excision of intraspinal (within the vertebral canal or spinal cord) lesion. The bone is removed to gain access to the lesion. These codes are selected according to location (cervical, 63304; thoracic, 63301-63302; or lumbar or sacral, 63307), approach (anterior, or anterolateral, transthoracic, thoracolumbar, or transperitoneal or retroperitoneal) and whether the dura (the fibrous membrane that forms the outer covering of the central nervous system) is entered, i.e., intra- or extradural. As with 63081-63091, report the appropriate code for the first vertebra removed, using add-on code 63308 for each additional segment. Arthrodesis and spinal reconstruction may be separately reported.
 
For example, says Richard Bucknell, MD, a practicing neurosurgeon in Philadelphia, the surgeon prepares to remove a lesion on the anterior spinal cord at segments C4 and C5. The vertebral-body resection is performed via an anterior approach and the dura is opened, exposing the tumor. The tumor is excised. Code the primary procedure 63304 and 63308. If reconstruction with instrumentation and grafts is performed, report these as explained in the previous example.

 
Like corpectomy codes 63081-63091, diskectomy codes 63075-63078 specify with decompression of spinal cord and/or nerve root[s] including osteophytectomy. However, these procedures include removal of intervertebral disk(s) and osteophyte(s) -- a bony outgrowth or protuberance -- on the upper and/or lower edges of the vertebral body only. The corpus, or body, of the vertebra remains intact. Again, the correct code is selected according to the level of the spine treated (63075, cervical; or 63077, thoracic).
 
Also, 63075 and 63077 specify single interspace, i.e., one space occupied by two adjacent vertebrae. Therefore, code selection should reflect the specific interspace treated, says Kathy Pride, CPC, CCS-P, coding supervisor for Martin Memorial Medical Group, a 55-physician group practice, including two neurosurgeons, in Stuart, Fla. Add-on codes 63076 and 63078 are used to report each additional interspace and are not subject to multiple-procedure reductions. The use of an operating microscope is an inclusive component of 63075-63078 and should not be billed, according to CPT. If only a minimal diskectomy is performed, it is included in the arthrodesis (in which case the arthrodesis would be the only reportable service).
 
For example, osteophytes at multiple thoracic levels are causing nerve compression in an elderly patient. The surgeon makes an anterior approach and, using the operating microscope, performs anterior diskectomy that extends to include the posterior osteophytes at the T5/T6, T6/T7 and T7/T8 interspaces. The surgery should be billed 63077, 63078 x 2.
 
If a lumbar diskectomy is performed, report 64999 (unlisted procedure, nervous system), Pride recommends. She predicts that the AMA will designate a specific code for this procedure.
 
Alternatively, some insurers may accept 63077 with modifier -22 (unusual procedural services) appended. Specify "lumbar not thoracic" in the "Comments" portion of the claim form.

 
Excision codes 22100-22103 also apply when a posterior component, rather than the body, of the vertebra(e) is removed. In this case, however, there is no decompression or diskectomy. These are strictly "bony" procedures.
 
Specifically, "The physician removes spurs, other growths or bone disease by partial resection of a posterior vertebral component such as spinous process, lamina or facet," according to Medicode's Coders' Desk Reference. Spinal reconstruction and arthrodesis are not indicated with these procedures. Select 22100 for the first excision at the cervical level, 22101 at the thoracic level, 22102 at the lumbar level, and 22103 for each additional segment.
 
Codes 22110-22116 (also "bony" procedures) describe procedures similar to corpectomy codes 63300-63308 and are easily confused, Bucknell explains. In each case, the vertebral body may be partially removed without decompression of the spinal cord or nerve root(s), as with 63081-63091. In this case, a portion of the vertebral body is removed to excise an intrinsic bony lesion (i.e., a lesion of the bone) rather than to gain access to the nerves (as with 63081-63091) or the spinal canal (as with 63300-63308). The first excision code is selected by location (22110, cervical; 22112, thoracic; 22114, lumbar), with 22116 reported for each additional segment. Arthrodesis and bone grafts may be billed separately.
 
For instance, the surgeon removes spurs from the spinous process at L2 and L3. Report the service 22102 and 22103. If intrinsic bony lesions at the same levels require that a corpectomy be performed, code 22114 with 22116, with any appropriate graft and arthrodesis codes.

 
Osteotomy codes 22210-22226 also describe removal of a portion of vertebral segment(s). These do not include decompression and involve more extensive bone removal than 63075-63078, although 22220-22226 may include diskectomy. The purpose of these procedures is not to release pressure from the spinal cord or nerve root(s) but to correct a deformity or remove a bone spur (exostoses or osteophyte) on the bone (and, therefore, a portion of the bone itself). The proper code is chosen by location and approach. For a posterior or posterolateral approach, select from 22210, cervical; 22212, thoracic; 22214, lumbar; and 22216 for each additional segment. For osteotomy including diskectomy via anterior approach, select either 22220, cervical; 22222, thoracic; or 22224, lumbar. Report 22226 for each additional segment.