Neurosurgery Coding Alert

Question: Our neurosurgeon performs ACDF surgeries with anterior cervical plate fixation using an operating microscope. We report this using 22554, 63075, 63076, 20931 and 69990. Is this correct?

Texas Subscriber

Answer: Appropriate coding depends on the circumstances of the surgery but, generally, the codes you list can apply when reporting an anterior cervical diskectomy and fusion (ACDF) procedure.
 
Carriers often reduce or deny ACDF even when it is reported properly because the descriptor for 22554 (arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2) specifies that minimal diskectomy to prepare the interspace is included in the fusion. This language may confuse carriers reviewing ACDF claims, and therefore documentation (an operative report) must prove that the disk removal was not a minimal diskectomy for fusion preparation but that it involved a decompression of nerve roots or removal of posterior osteophytes (bone spurs).
 
The computerized edits used by some carriers may reject the claim, so you must contact the carrier and explain that a proper decompression was performed.
 
Code 63075 (diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) is appropriate only if a nerve or canal decompression is performed. Each additional interspace may be reported using 63076 (... cervical, each additional interspace [list separately in addition to code for primary procedure]). Although these codes may be denied initially, they should be paid on appeal. If two levels of diskectomy are performed, two levels of fusion should be reported.
 
Code 20931 (allograft for spine surgery only; structural) is correct if a structural allograft (a graft not harvested from patient) is used. Such allografts use bone from a bone bank. Usually, a groove is carved into the front of the vertebra, in the interspace, where the graft is placed. The pressure of the two vertebrae being pressed against one another holds the graft in place and provides anterior stability. Report the allograft code only once, regardless of the number of levels addressed.
 
Some coders have reported success billing 20931 and 20931-59 (distinct procedural service) for multiple levels, although an appeal is often needed to get the claim paid (note that the language in CPT instructing providers to bill only one bone graft [20930-20939] per operative session was eliminated in 2001). With this method, be sure to include an operative report clearly illustrating that two separate interspaces (e.g., C5/C6 and C6/C7) were treated.
 
Use of the operating microscope (69990, use of operating microscope [list separately in addition to code for primary procedure]) is an inclusive component of 63075 and should not be reported separately for Medicare. Some private payers may reimburse separately.