Neurosurgery Coding Alert

Question: Our surgeon recently performed a laminectomy for biopsy and excision of an intraspinal neoplasm and, at the same time, placed posterior segmental instrumentation. My understanding is that I must bill arthrodesis to report instrumentation, but the surgeon did not list an arthrodesis in the operative report. Can I still code for the instrumentation?

Florida Subscriber Answer: Surgeons place instrumentation to help stabilize the spinal cord. As in the case you cite, this can result from (among other causes) a loss of bone mass following spinal tumor excision.
 
But the instrumentation codes (22840-22851) are add-on codes "reported separately and in addition to arthrodesis," according to CPT. Your first step should be to speak with the operating surgeon to determine if he performed some type of arthrodesis prior to placing instrumentation but simply neglected to note it in the operative report. (Remember that "arthrodesis" is a fairly generic term describing several different techniques from rudimentary to very involved.)
 
If the surgeon did perform arthrodesis, simply report it along with the instrumentation, as usual. For example, for arthrodesis with instrumentation spanning three thoracic levels, report 22610 (Arthrodesis, posterior or posterolateral technique, single level; thoracic [with or without lateral transverse technique]), +22614 x 2 (... each additional vertebral segment [list separately in addition to code for primary procedure]) and 22842 (Posterior segmental instru-mentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments).
 
If the surgeon did not perform arthrodesis of any type, your best choice may be to report 22899 (Unlisted procedure, spine) for instrumentation placement. Send an operative report describing the procedure and noting the "closest" available instrumentation code (in the example, 22845, Anterior instrumentation ...) so the payer has a "reference point" to determine payment. Do not be surprised if the payer initially rejects the claim. You (or, more specifically, your surgeon) should be ready to defend the medical justification of placing the instrumentation.