Neurosurgery Coding Alert

Question: Our surgeon did suboccipital craniectomy with C1 and C2 laminectomies, occipital C1, C2, C3 posterior segmental instrumentation, and occipital C1, C2, C3 posterior and posterolateral arthrodesis. The diagnosis was occipital cervical instability, basilar invagination, brainstem compression, C1-2 stenosis with myelopathy and rheumatoid arthritis. How do we report this? The patient was given cervical traction for the instability.

Georgia Subscriber

Answer:  If the cervical traction was placed intraoperatively for the procedure, it would be considered a bundled service and not separately reportable. However, if the cervical traction was placed on a previous day in the ICU and/or in the patient's room in order to achieve preoperative reduction in anticipation of surgery, the traction could be reported separately with 20660 (Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)) or 20661 (Applicationn of halo, including removal, cranial). Modifier 59 (Distinct Procedural Service:...) may be required if the traction is instituted within the preoperative global period of the surgical procedure.