Neurosurgery Coding Alert

Question: Which code (or codes) should I use to report PLIF without posterolateral fusion at L5-S1?


Texas Subscriber

Answer: The primary procedure involved in posterior lumbar interbody fusion (PLIF) is 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar).

In addition to the arthrodesis (22630), you should also report any bone grafts the surgeon places. The most common graft code with PLIF is 20931 (Allograft for spine surgery only; structural) for bone that came from a bone bank, or 20938 (Autograft for spine surgery only [includes harvesting the graft]; structural, bicortical or tricortical [through separate skin or fascial incision]) for bone that came from the patient's own body.

You should also code for any pedicle screw fixation (instrumentation) that the surgeon uses to stabilize the spine.

In this case, the physician performs the pedicle fixation across one interspace (L5-S1). To report the pedicle fixation, use 22840 (Posterior non-segmental instrumentation [e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation]).

Remember: Both the bone grafting procedure (20931 or 20938) and the instrumentation placement (22840) are exempt from modifier 51 (Multiple procedures).