Neurosurgery Coding Alert

Question: Our surgeon did the following procedure:

Removal of cervical plate C5-C7; anterior cervical discectomy, and allograft fusion and anterior instrumentation, C3-C5.

How do we report this procedure? In specific, how do we report the removal of the cervical plate? Is 22855 (Removal of anterior instrumentation) the correct code for the removal of the cervical plate?

Ohio Subscriber

Answer: Assuming that a two interspace discectomy was performed, for the C3-4 discectomy and arthrodesis that your surgeon does, you report 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2). For the C4-5 interspace, you include +22552 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace [List separately in addition to code for separate procedure]) for the same at C4.

For cervical plate removal, you report 22855 (Removal of anterior instrumentation) and append modifier 59 (Distinct procedural service). Since the site of instrumentation removal is distinct from the site of the new instrumentation, both fixation removal and a new placement of instrumentation are separately reportable.

For the anterior instrumentation, you report 22845 (Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to code for primary procedure]) and for allograft you report 20931 (Allograft, structural, for spine surgery only [List separately in addition to code for primary procedure]).