Neurosurgery Coding Alert

Question: Our surgeon recorded the following procedures.

"The patient was pinned in the Mayfield head holder and with six assistants we carefully turned the patient onto the gel rolls, being sure to maintain neutral alignment. Her C-collar was removed at this point in time. C-arm fluoroscopy was brought into the field to identify the occiput down to the level C4 on lateral imaging which was easily visible. The patient was then prepped and draped in the typical sterile fashion. A midline incision was made from the occipital protuberance down to about the level of C5. This incision was carried down to the midline, down to the lamina. C1, C2, C3, C4 were easily identified as was the occiput. After retractors were put into place, we began placing our lateral mass screws into C2, C3, and C4. We utilized 14 mm variable angled screws into C2, and C4 on the right hand side with a 12 mm into C3. On the left hand side we utilized 14 mm screws into C2 and C3 and a 12 mm into C4. These were all placed under direct lateral guidance. They were all placed in a very similar fashion utilizing the high speed B1 style drill bit to create a small cortical opening and then the screws were predrilled to a depth of either 12 or 14 mm and then palpated with a small ball probe to be sure that bone was on all 4 sides. The screws were then placed under direct lateral guidance.

Next, we began our trial fitting for the Stryker occipital plate. We ultimately chose a small Stryker occipital plate, marked out how it would fit on the occipital in preparation for our decompression. First we decompressed the C1 ring and removed the posterior aspect of the C1 ring. Next, we used the high speed Stryker drill to remove the superior aspect of the C2 spinous processes and lamina down to the level of the ligamentum flavum. Next we utilized the high speed Stryker drill to remove the occiput about 2.5 cm high. We removed this out laterally to create a significant amount of foramen magnum decompression. After we had our occipital decompressed we then placed the occipital plate. This was placed with 4 screws of 66 mm screws affixed to the occiput. We then aligned all of our screw heads chose two 70 mm straight rods which we bent into shape. These were affixed to the screws with locking caps. Once the rod and caps were placed the screws were final tightened. At this point in time, the lamina running from C2 down to C4 were then roughed up with the high speed Stryker drill and Vitoss as well as autograft was laid for interlaminar as well as facet fusion.

After we were happy with the amount of posterolateral fusion the patient was irrigated profusely throughout the case, but also at this time with antibiotic solution and closed in a multilayer fashion, 0 Vicryl done in 2 layers for the muscle and fascia, 2-0 Vicryl and finally a running 3-0 nylon suture were used to complete the skin layer of closure. All neuro monitoring remained at baseline throughout the entire case."

How do we report this case?

Florida Subscriber

Answer: While the procedure described is performed for C2 pannus and not Chiari malformation, for the surgical decompression of the suboccipital area along with the cervical laminectomies of C1 and C2 you will report code 61343 (Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft [e.g., Arnold-Chiari malformation]).

The posterior occipitocervical fusion is reported with 22595 (Arthrodesis, posterior technique, atlas-axis [C1-C2]) (occiput to C2), 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment ) (C2-C3), and +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) (C3-C4).

For posterior segmental fixation you turn to +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]). You report local laminar autograft with +20936 (Autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinous process, or laminar fragments] obtained from same incision [List separately in addition to code for primary procedure]).