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Neurosurgery Coding Alert

Let Vocabulary Be Your Guide When Selecting Among Spinal Codes

Published on Sun Jun 01, 2003

Coders trying to decipher operative reports cannot always easily tell the difference among anterior vertebral corpectomy (63081-63091), anterior diskectomy (63075-63078), partial excision (22100-22103, 22110-22116) and osteotomy of spine (22210-22226). By carefully searching documentation for key words and phrases, you can more accurately identify these procedures and ensure appropriate reporting.

Know Your Terms

The best method to distinguish among spinal procedures is simply to know your terminology. For example, anterior vertebral corpectomy (also called vertebral body resection) involves complete or near complete removal of the vertebral body (corpus = body, and ectomy = removal). The surgeon may perform the procedure either with (63081-63091) or without (63300-63308) decompression of the spinal cord and/or nerve root(s). In the case of 63300-63308, the corpectomy is not the goal of the procedure. Rather, the bone removal is necessary to access and remove an intraspinal lesion(s). All vertebral corpectomy procedures include diskectomy (that is, removal of the adjacent intervertebral disks).

Like 63081-63091, 63075-63078 include decompression of the spinal cord, but these procedures describe removal of intervertebral disc(s) and osteophyte(s) (osteo = bone, and phyte = growth) only. The body of the vertebra remains intact, and therefore these procedures are somewhat less extensive than either 63081-63091 or 63300-63308.

Excision codes 22100-22103 can also apply when the surgeon removes a posterior component (for instance, the spinous process), rather than the body, of the vertebra(e). In this case, however, there is no decompression or diskectomy. These are strictly "bony" procedures to remove damage or disease.

Finally, osteotomy codes 22210-22226 also describe removal of a portion of vertebral segment(s) (osteo = bone, and otomy = incision or "cutting into"). These procedures do not include decompression (in contrast to 63081-63091), but 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 spinal deformity," says Kee D. Kim, MD, associate professor in the department of neurosurgery at the University of California at Davis in Sacramento.

With a basic understanding of terminology, you can search the operative report for key words that will allow you to select the appropriate code category (see article "Search for Key Words").

Note: Always be sure to read the operative report thoroughly and not just the procedure descriptor at the top. The "named" procedure and "described" procedure do not always match. When in doubt, code according to the body of the operative report.

Don't Report Fracture Repair With Corpectomy

If the surgeon repairs spinal fracture with a vertebral corpectomy (as is often the case), the latter is the definitive treatment. You may not report fracture care treatment codes in addition to 63081-63091. On the other hand, you may separately bill arthrodesis (22548-22812, to stabilize the spine) and spinal reconstruction procedures, including bone grafts (20930-20938) and spinal instrumentation (22840-22855). Bone graft and instrumentation codes, although not specifically defined as add-on procedures, "are reported in addition to codes for the definitive procedure(s)," according to CPT.

Assign the appropriate corpectomy code according to 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 and, if the surgeon removes additional segments, list removal of the second and any subsequent vertebral bodies using the appropriate code(s) for "each additional segment," says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues, in Fountain Valley, Calif. Note that the "multiple surgery" concept does not apply to add-on codes 63076, 63078, 63082, 63086, 63088 and 63091 for each additional segment, and insurers should reimburse these codes at their full value.

For example, to treat a compressed nerve caused by fracture, the surgeon performs diskectomies followed by corpectomy of segments C3 and C4. She frees compressed nerve roots and reconstructs the spine using a tricortical allograft and titanium plates. Appropriate coding is:

  • 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.

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

    Intraspinal Lesion Requires 63300-63308

    Codes 63300-63308 describe removal of the vertebral body to gain access to an intraspinal lesion. Select these codes 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 (the fibrous membrane that forms the outer covering of the central nervous system). If the surgeon cuts into the dura, it is an "intradural" procedure. As with 63081-63091, report the appropriate code for the first vertebra removed, using add-on code 63308 for each additional segment. As with 63081-63091, you may claim arthrodesis and spinal reconstruction separately.

    For example, the surgeon uses an anterior approach to access segments C4 and C5, opening the dura and exposing the tumor for excision. In this case, report the primary procedure using 63304 and 63308. You may report any grafts and/or instrumentation for spinal reconstruction separately, as above.

    Report Osteophytectomy Per Interspace

    Osteophytectomy codes 63075 and 63077 specify "single interspace" (that is, one space between two vertebrae), and therefore your code selection should reflect the specific interspace treated. You should use add-on codes 63076 and 63078 to report each additional interspace.These codes are not subject to multiple-procedure reductions. For example, taking an anterior approach and using the operating microscope, the surgeon performs anterior diskectomy 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 an inclusive component of 63075-63078).

    Note: For anterior lumbar diskectomy (for which there is no specific CPT code), report 64999 (Unlisted procedure, nervous system). 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.

    22100-22226 Mean Bone Only

    As noted above, excision codes 22100-22103 are strictly "bony" procedures, and spinal reconstruction and arthrodesis are not indicated with these surgeries. Select 22100 for first excision at the cervical level, 22101 at the thoracic level, 22102 at the lumbar level and 22103 for each additional segment regardless of level.

    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 root(s). 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.

    Once again, you should select the first excision code by location (22110, cervical; 22112, thoracic; 22114, lumbar) and report 22116 for each additional segment. You may report arthrodesis and bone grafts separately, if performed.

    Osteotomy codes 22220-22226 describe removal of a portion of vertebral segment(s), in this case to correct spinal deformity, Kim says. These generally do not include decompression and involve more extensive bone work than 63075-63078 anterior approach codes that are otherwise quite similar to the anterior osteotomy codes 22220-22226, which may also include diskectomy. Choose the proper code by location and approach. For 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, with 22226 for each additional segment.

     

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