Neurosurgery Coding Alert

To get the most out of your spinal instrumentation claims, you must consider procedures beyond placement of the instrumentation itself. In part 2 of this two-part series, we discuss four more ways you can ensure accurate and complete instrumentation coding, every time.

You should use +22848 (Pelvic fixation [attachment of caudal end of instrumentation to pelvic bony structures] other than sacrum [list separately in addition to code for primary procedure]) to describe fixation of the distal (or caudal, "closer to the tailbone") portion of posterior instrumentation to the pelvis. This may occur, for instance, to correct scoliosis extending to the pelvis (which causes the pelvis to tilt). Code 22848 applies regardless of whether the surgeon attaches segmental or non-segmental instrumentation.

Important: You should report 22848, like all instrumentation codes, in addition to a primary procedure code, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. CPT 2008 provides a full list of procedures with which you may claim 22848.

Also, +22841 (Internal spinal fixation by wiring of spinous processes [list separately in addition to code for primary procedure]) describes a secondary posterior procedure in which the spinous process (the bony prominence projecting rearward from the vertebra) of two or more vertebral segments are wired together (for instance, to promote fusion of bone grafts). Medicare bundles this service, so you will not receive separate reimbursement for it.

You should not append modifiers 50 (Bilateral procedure) or 51 (Multiple procedures) to codes describing spinal instrumentation.

Here's why: CPT defines instrumentation procedures as inherently bilateral, so you should never use modifier 50, Parks say.

In addition, all codes describing placement of instrumentation (22840-22848, 22851) are exempt from multiple-procedure (modifier 51) adjustments, according to CPT.

Explanation: Because a surgeon would never report instrumentation alone (at minimum, he would also perform arthrodesis), the value assigned to these add-on codes already takes into account their status as "additional" but independent procedures.

"Instrumentation codes-are valued for -intraoperative- work only," says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network. "There is no preoperative or postoperative work value. Therefore, they must be reported with a primary code, such as arthrodesis, but may also be reported with fracture and/or dislocation or exploration of fusion codes as well."

Nor would you report modifier 59 (Distinct procedural service) with spinal instrumentation codes, except to denote different levels for cage placement, as explained in part 1 of this series (Neurosurgery Coding Alert, Vol. 8, No. 11, pp. 81-83).

When reporting follow-up instrumentation procedures during the 90-day global period of an initial surgery, you may need to use modifiers.

To make modifier use easy, follow these examples:

- If the surgeon must return the patient to the operating room to remove instrumentation during the global period (for instance, if the patient's body rejects the device or the instrumentation migrates), you should append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to the appropriate removal code, Grady says.

Example: For removal of posterior nonsegmental instrumentation during the global period of the initial surgery, report 22850-78.

- If the surgeon must perform an unrelated spinal procedure during the global period of a previous fusion/instrumentation placement, append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to the appropriate procedure code.

Example: If the surgeon must perform a fusion of cervical vertebrae during the global period of a thoracic fusion/instrumentation, report 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2) and append modifier 79.

- If the surgeon removes instrumentation from a previous surgery (for which the global period has expired), you need not append any modifiers.

Example: One year after placing instrumentation (segmental), the surgeon returns the patient to the operating room, removes the instrumentation and performs additional fusions. In this case, you should report 22852 (Removal of posterior segmental instrumentation).

4. Report Arthrodesis, Bone Grafts Separately

When reporting spinal instrumentation codes, be sure to report arthrodesis procedures, as well as bone grafts, separately, Grady says. Each of these procedures is distinct and deserves separate payment. In fact, because add-on codes describe all placement-of-instrumentation codes, you must report a primary procedure (such as arthrodesis) separately with the instrumentation codes.

Beware of these payment exceptions: If you report bone graft codes +20930 (Allograft for spine surgery only; morselized) or +20936 (Autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinous process, or laminar fragments] obtained from same incision), don't expect to collect -- at least from Medicare payers. Medicare assigns no relative value units (RVUs) to 20930 or 20936 and considers them to be bundled services, according to the latest physician fee schedule database. Therefore, Medicare payers will always bundle payment for these codes into the more extensive procedure (for instance, the arthrodesis reported at the same time).

Example: The neurosurgeon performs arthrodesis at C5-C6 with structural allograft and anterior Accufix plating. In this case you would report:

- 22554 (arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2) for the fusion

- +20931 (Allograft for spine surgery only; structural) for the bone graft

- +22845 (Anterior instrumentation; 2 to 3 vertebral segments) for the instrumentation.