Neurosurgery Coding Alert

Question: We are attempting to code the following: anterior lumbar diskectomy, L4-5 via retroperitoneal approach, with anterior stabilization using threaded bone dowels and anterior arthrodesis bilaterally. What codes should be used?

Montana Subscriber

Answer: Its difficult to suggest precise coding without an operative report, says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, a coder who specializes in surgical and neurosurgical procedures. The following scenarios should be of assistance.

1. If a diskectomy is performed with no decompression of the nerve, bill 22558 (arthodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression, lumbar]) with 20931 (allograft for spine surgery only, structural) for the bone graft (threaded bone dowels).

2. If a diskectomy and arthrodesis are performed with the decompression of the nerve, bill 22558, 63090-52 (vertebral corpectomy [vertebral body resection], partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment, reduced services), and 20931 for the bone graft.

3. If a portion of the vertebrae is removed during the diskectomy and arthrodesis with decompression of the nerve, bill 63090, 22558-51 (the modifier is appended to inform the carrier that this charge is subject to a multiple surgical reduction), and 20931 for the bone graft.

Note: In the second scenario, 63090 is billed second because it is a reduced procedure. In the third scenario, 63090 becomes the primary procedure because of its higher relative value.

4. Code 63091 (vertebral corpectomy, each additional segment, [list separately in addition to code for primary procedure]) is an add-on code and should be used only if a portion of the second vertebrae is removed. If only the disk is removed, 63091 should not be used.

5. If an anterior instrumentation such as a synthes plate is used, then code 22845 (anterior instrumentation; two to three vertebral segments) should be added.

When neurosurgeons perform multiple surgical procedures on a patient, many major independent carriers pay 100 percent of the first coded procedure, 50 percent of the second, and 50 percent of the third, following Medicare's guidelines. Some third-party payers, however, may follow a 100 percent, 50 percent, 25 percent rule, and some may employ the multiple procedure rules. In these cases, the precise manner in which the procedures are billed becomes paramount to ensuring maximum reimbursement.

Often, a surgeon will bill these codes in the order that he or she wrote them down in the operative notes. Coders do not have to bill in the order that the surgical procedures are performed, nor does billing have to be done anatomically. If the coder is dealing with a carrier that automatically will reduce reimbursement as it goes down the list, the most financially rewarding way to code is to put the most expensive primary procedures at the top of the list and work down.