Neurosurgery Coding Alert

Question: My physician removed an Atlantis plate and screws at C6-7, performed a routine anterior cervical fusion, harvested a bone graft from the right iliac crest, and inserted a new Atlantis plate and screws. He used fluoroscopic guidance for the procedure. The neurosurgeon thinks we should report 22554-22, 22855-51, 22845, 20938, and 76000-26, but I disagree. Would  you tell me what we should report?


Oregon Subscriber

Answer: Your neurosurgeon is correct that you should first report 22554 (Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2) for the cervical fusion. Unless the op report states that there were complications or an unusual circumstance and that the time and difficulty of the procedure increased, you should not append modifier 22 (Unusual procedural services).

The coding confusion occurs because of a lack of clarity in the CPT definitions and National Correct Coding Initiative bundling edits. You could use 22849 (Reinsertion of spinal fixation device) by itself and append modifier 51 (Multiple procedures), but you wouldn't get credit for the plate removal. This is because NCCI bundles 22855 (Removal of anterior instrumentation) with 22849. You wouldn't use modifier 59 (Distinct procedural service) to override this edit because the neurosurgeon is not performing the procedures at separate locations.

Alternatively, you could use 22855 for the removal and append modifier 51. Then, report 22845 (Anterior instrumentation; 2 to 3 vertebral segments) for the replacement of the plate and screws. This, however, doesn't indicate that this was not a new instrumentation. Because 22845 does not necessarily require that it be an initial placement -- and because the surgeon typically places a new plate and doesn't reinsert the previous plate -- this is the preferred coding.

Finally, you should report 20938 (Autograft for spine surgery only [includes harvesting the graft]; structural, bicortical or tricortical [through separate skin or fascial incision]) for the bone graft.

Beware: You should not report the fluoroscopic guidance because NCCI bundles 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71203 and 71034 [e.g., cardiac fluoroscopy]) into the arthrodesis procedure and Medicare won't separately pay on it.