Neurosurgery Coding Alert

Question: Our neurosurgeon explored spinal fusion at he same level he performed single posterior lumbar arthrodesis. Can we bill for the exploration?

Nevada Subscriber

Answer: You can code an arthrodesis with 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]), plus the exploration (22830, Exploration of spinal fusion) -- in some circumstances.

Explanation: If your surgeon performed a more definite procedure at the same level of the exploration, you should only code for that procedure instead of the exploration. In your example, since your surgeon performed the arthrodesis at the same level, you should only report the arthrodesis. Current Correct Coding Initiative (CCI) guidelines, however, state that you can report both codes during the same encounter and append modifier 59 (Distinct procedural service) to 22830 -- if you have supporting documentation showing the need for both procedures and the procedures are performed at separate sites. Check with your payer to verify the correct way to file before submitting the claim.