Neurosurgery Coding Alert

Question: Our surgeon did removal of segmental instrumentation, a 3 column osteotomy spinal cord decompression and laminectomy of T1, open treatment of fracture/ dislocation of C7 on T1 posterior cervical fusion of C2-T4; segmental instrumentation of C2-T4 complex; and use of local bone graft, BMP, and mastergraft. Could you suggest the appropriate ICD-9 and CPT® codes for this procedure?

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Answer: You cannot report the three column osteotomy presumably performed at C7-T1, along with the open treatment of a C7-T1 fracture/dislocation, if performed at the same level. In other words, you cannot report code 22206 (Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment [e.g., pedicle/vertebral body subtraction]; thoracic) and 22327 (Open treatment and/or reduction of vertebral fracture[s] and/or dislocation[s], posterior approach, 1 fractured vertebra or dislocated segment; thoracic) for the same spinal level.  Unless performed at different levels, one must choose one code or the other.   Code 22327 is applied to traumatic spinal injuries and includes laminectomy, facetectomy and foraminotomy, if performed.  

Since the physician removed instrumentation and placed new instrumentation, you should not report the instrumentation removal code separately. You only report the posterior segmental instrumentation code, +22843 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 7 to 12 vertebral segments [List separately in addition to code for primary procedure]).  Given that instrumentation was already present (though the levels were not specified), one would anticipate that some spinal levels were previously fused. You can report either 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment) or 22610 (Arthrodesis, posterior or posterolateral technique, single level; thoracic [with lateral transverse technique, when performed]) for the initial fusion level. Then, you should report +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) for each additional fusion level provided that a fusion is not already present.  

You may also report the local bone graft 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]) and BMP/mastergraft with code 20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only [List separately in addition to code for primary procedure]).