Neurosurgery Coding Alert

Question: In a patient diagnosed with cervical fracture C7-T1, our surgeon did a C7-T1 posterior decompressive laminectomy, posterior lateral fusion of C5-T3 and fixation of C5-T3. How do we report this?

New York Subscriber

Answer: For the surgery performed in the posterior cervicothoraic spine, the laminectomy reported does not include description of facetectomy and/or foraminotomy. The posterior instrumentation also needs specification for the number of segments that have fixation to differentiate non-segmental from segmental instrumentation.

You will report the posterior decompression procedure with code 63001 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy [e.g., spinal stenosis], 1 or 2 vertebral segments; cervical) and append modifier 51 (Multiple procedures). For arthrodesis, you report 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment) and 22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) x 4.

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]) which is for 3-6 vertebral segments and covers C5, C6, C7, T1, T2, and T3 if there are at least three segments in which fixation is placed. Additionally, bone graft harvest codes may also be applicable if performed.