Neurosurgery Coding Alert

Question: The patient being treated by our surgeon hit a bump in the road and she flew up and hit the roof of the car with her head resulting in severe flexion of her neck. The MRI showed severe subluxation of C7-T1 with bilateral jump facet. Additionally, the patient was reported to have severe central canal stenosis and cord compression resulting in myelopathy.

Our surgeon performed an open reduction of C7-T1 locked facet (fracture) after performing a laminectomy at C7-T1. Following this, he did an anterior cervical discectomy and fusion C7-T1 using screws, plate and cage. Then, he went back and did the posterior cervical thoracic fusion C5-T2 using lateral mass screws, pedicle screws and rods.

How can we report this? Can we code the laminectomy (63045) with the reduction procedure (22326)? What could be the best code for the open reduction of the locked facet?

New Jersey Subscriber

Answer: You report code 22326 (Open treatment and/or reduction of vertebral fracture[s] and/or dislocation[s], posterior approach, 1 fractured vertebra or dislocated segment; cervical) for the open reduction of the cervical vertebral fracture. Note that laminectomy is inclusive in 22326 for the C7 and T1 levels. You do not separately report 63045 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis], single vertebral segment; cervical). For anterior cervical discectomy and fusion, you report code 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2) and append modifier 51 (Multiple procedures).

You also report code +22845 (Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to code for primary procedure]) and +22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cage(s), methylmethacrylate] to vertebral defect or interspace [List separately in addition to code for primary procedure]) for the anterior instrumentation and biomechanical device.

You report the posterior cervical thoracic fusion, C5-T1, with codes 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment) appended with the 51 modifier (Multiple procedure) and +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) x 3. For posterior instrumentation, you report code 22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure]).