Neurosurgery Coding Alert

Question: Encounter notes indicate that the neurosurgeon treated a patient with thoracic postural kyphosis. From the surgeon: “performed bony excision/3 column approach. Removed bone from the back and both vert. columns.” The surgeon then performed the same bony excision on two more vertebrae. How should I report this encounter?

RCI Subscriber

Answer: Your surgeon performed an osteotomy on three vertebral segments for this patient, which means you can report a trio of CPT^® codes.

On your claim, report:

• 22206 (Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic) for the initial osteotomy
• +22208 (… each additional vertebral segment (List separately in addition to code for primary procedure)) x 2 for the osteotomies the surgeon performed on the other two segments
• M40.04 (Postural kyphosis, thoracic region) appended to 22206 and +22208 x 2 to represent the patient’s kyphosis.

More on this condition: Patients who have postural kyphosis often need treatment from a spinal surgeon. The condition’s main feature is outward curvature of the patient’s upper back. Other symptoms include:

• Rounded shoulders
• Forward head posture
• Back pain or stiffness
• Fatigue from increased physical effort to maintain posture
• Mobility issues in the upper back and neck

Postural kyphosis is typically associated with poor posture rather than any intrinsic spinal issue. Patients with postural kyphosis will often have a “hunched” appearance; their complaints of back pain or stiffness often come after long periods of sitting or standing. Causes of postural kyphosis include:

• Sedentary lifestyle
• Prolonged sitting
• Poor ergonomics while sitting
• Weakness in muscles used to maintain posture, like back extensors
• Chest muscle tightness.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC