Neurosurgery Coding Alert

Question: Our neurosurgeon completed right L3-4 translumbar interbody fusion with cage and pedicle screw fixation. He used the Zimmer Optima Pedicle Screw System and bilateral posterolateral fusion with BMP. How should I code this surgery?

Oklahoma Subscriber

Answer: This is a complicated case, so you'll report several codes:

• 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) for the interbody fusion

• 22612-51 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique])-(Multiple procedures) for the posterior fusion

• +22851 (Application of intervertebral biomechanical devices[s] [e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace [List separately in addition to code for primary procedure]) for the PEEK cage

• +20930 (Allograft for spine surgery only; morselized [List separately in addition to code for primary procedure]) for the bone morphogenic protein

• +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] [List separately in addition to code for primary procedure]) for the instrumentation.

Missed opportunity: It appears that your surgeon also used local bone graft, but he didn't document the harvest or that it was local autograft. If this were the situation and he had documented the details, you could have also reported +20936 (Autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinous process, or laminar fragments] obtained from same incision [List separately in addition to code for primary procedure]).

Modifier check: These types of cases might involve co-surgeons working together to complete the  procedure(s). If so, you'll need to append modifier 62(Two surgeons) to the appropriate codes (such as the posterior fusion).