Neurosurgery Coding Alert

Question: Patient had a TLIF/laminectomy. Our surgeon removed the patient’s previous screws and an interspinous plate. He replaced the screws during the procedure. Can we consider reporting codes 20680 or 22852? How do we distinguish between these codes?

Codify Subscriber

Answer: Based on the limited information provided, it is difficult to provide a definitive.  For the scenario described and assuming additional instrumentation was not placed at the same session, you would best report code 22852 (Removal of posterior segmental instrumentation) and not code 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]).

However, you’ll encounter a number of limitations for reporting the removal of spinal instrumentation.  CPT® states that only the appropriate insertion codes (22840-22848) should be reported when previously placed spinal instrumentation is being removed or revised during the same session where new instrumentation is inserted at levels including all or part of the previously instrumented segments. You should not report reinsertion 22849 or removal (22850, 22852, 22855) procedures in addition to the insertion of new instrumentation (22840-22848).

If your surgeon removed the screws but didn’t insert new ones, you have two coding choices depending on the original procedure. Code with 22852 if the screws were pedicle screws that were part of a previous lumbar-spinal fusion. If the screws were for an old pelvic fracture, your most likely choice is 20680. Append modifier 52 (Reduced services) to the procedure code if the surgeon didn’t remove all instrumentation. If, however, the surgeon inserted new pedicle screws replacing the original ones in the same locations, you may report 22849 (Reinsertion of spinal fixation device) without using an insertion of spinal instrumentation code. No modifiers or other codes are necessary.

Explanation: Surgeons sometimes use iliac screws during spinal fusion cases to anchor or attach plates or rods going up to the lumbar spine. CPT® includes specific codes for spinal instrumentation insertion and removal, and your example definitely involves deep hardware.