Neurosurgery Coding Alert

Question: The surgeon completed anterior exploration with biopsy and diagnosed an anterior cervical abscess with osteomyelitis at C5-C6. Two days later he performed anterior discectomy and decompression of abscess with cadaver bone fusion. What codes apply?

Maine Subscriber

Answer: If the surgeon biopsied the vertebra for diagnosis of osteomyelitis, code the first procedure with 20251 (Biopsy, vertebral body, open; lumbar or cervical). CPT does not include a code for open biopsy of the intervertebral disc, so report 22899 (Unlisted procedure, spine).

The second surgery is a larger, more definitive procedure that includes debridement and decompression  along with arthrodesis. Code the surgery with 63075 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace), +22845-51 (Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to code for primary procedure]; Multiple procedures), and +20931 (Allograft for spine surgery only; structural [List separately in addition to code for primary procedure]).

Also append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to each of these codes to reflect the additional surgery performed within the global period of the biopsy.

Your best diagnosis choices are 722.91 (Other and unspecified disc disorder; cervical region) or 730.08 (Acute osteomyelitis; other specified sites).