Neurosurgery Coding Alert
Receive Proper Reimbursement for Spinal Instrumentation Procedures
Coding for placement of spinal instrumentation can be complicated by several factors, including the need to identify properly the type of instrumentation and the number of spinal levels spanned. And, instrumentation is often placed during a procedure in which two surgeons work together, complicating documentation and coding requirements. Last, coders must know how to report removal of instrumentation and/or postsurgical complications. Determine Location First Instrumentation may consist of rods, cages, plates, wires and/or other mechanical devices. When you choose CPT code(s) to report a procedure, however, the location of the instrumentation rather than the type is the most important selection criteria. Instrumentation may be either anterior (attaching to the front portion of the spine or vertebral segment) or posterior (attaching to the back of the spine or vertebral segment). Posterior instrumentation, which is more common, may be further classified as segmental or nonsegmental. Note: Generally, the surgical approach (anterior or posterior) will correspond to the location of the instrumentation. Nonsegmental posterior instrumentation attaches to the spine at two points only the proximal and distal portions (top and bottom) of the rod or other device with no attachment to any vertebra between those points. For example, a rod spanning from the first to fifth lumbar levels is attached to the spine at L1 and L5 but would not be attached at L2, L3 or L4. Placement of nonsegmental posterior instrumentation is reported using 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.) Note: Instrumentation procedures are reported according to the number of interspaces (i.e., the spaces between vertebral segments, such as L1/L2) spanned, while fusion is reported according to the number of segments (i.e., vertebral segments, such as L1, L2) spanned. Code 22848 (Pelvic fixation [attachment of caudal end of instrumentation to pelvic bony structures] other than sacrum) is used to describe fixation of the distal (caudal literally closer to the tailbone"") portion of posterior instrumentation (segmental or nonsegmental) to the pelvis for instance" to correct scoliosis extending to the pelvis causing it to tilt. Report 22848 in addition to the primary instrumentation code (e.g. 22842). Last 22841 (Internal spinal fixation by wiring of spinous processes) describes a secondary posterior procedure in which the spinous process (the bony prominence projecting rearward from the vertebra) of two or more vertebral segments are wired together (for instance to promote fusion of bone grafts). This service is bundled by Medicare. Placement of anterior instrumentation is reported using 22845 (Anterior instrumentation; 2 to 3 vertebral segments) 22846 ( 4 to 7 vertebral segments) and 22847 ( 8 or more vertebral segments) as determined by the number of vertebral segments spanned (there is no distinction between segmental and nonsegmental anterior instrumentation). Anterior instrumentation usually involves application of plates that are screwed directly onto the vertebrae whereas posterior instrumentation involves placement of rods or other apparatus that grip the lamina or are screwed into the pedicles. CPT also includes a specific code to describe application of devices such as cages or bone dowels and use of bone cement (methylmethacrylate): 22851 (Application of intervertebral biomechanical device[s] [e.g. synthetic cage(s) threaded bone dowel(s) methyl-methacrylate] to vertebral defect or interspace). Bill one unit of 22851 for each level or interspace the instrumentation is used on. Append modifier -59 (Distinct procedural service) to the second and subsequent units of 22851 to indicate that the procedure was performed at several distinct anatomic locations. For example if synthetic cages are placed at the L1-L2 and L2-L3 interspaces report 22851 22851-59. Documentation must substantiate that the instrumentation was placed at different levels. If more than one cage or other device (or combination of devices included in 22851) is placed in the same intervertebral space at the same level report a single unit of 22851. Multiple units reported for the same anatomic location will be rejected as a duplication of services. Don't Stand for Fee Reductions All instrumentation codes 22840-22848 and 22851 are modifier -51 (Multiple procedures) exempt. Although instrumentation procedures are never performed alone (at minimum they are accompanied by a fusion procedure) 22840-22848 and 22851 are not "add-on" codes. Rather the relative value units (RVUs) assigned to them reflect their status as "additional" but independent procedures that must be reported in addition to the primary procedure. For this reason payers should not reduce payment for instrumentation procedures on the grounds that they are add-on or secondary procedures explains Anita Daye Foster MA CPC of The Coding Network which provides coding services to academic environments in Beverly Hills Calif. For example the neurosurgeon removes two lower thoracic vertebrae (T10 and T11) shattered as a result of trauma followed by arthrodesis and spinal reconstruction with bone grafts. The procedure would be reported as follows: Code 22842 should be reimbursed at its full RVU amount (about 21.00) although it is one of multiple procedures performed during the same operative session. Neurosurgery practices should carefully scan the explanation of benefits for all instrumentation claims to be sure that there are no inappropriate fee reductions. Instrumentation codes are inherently bilateral. Therefore modifier -50 (Bilateral procedure) is not necessary and payment is not increased if instrumentation is placed on either side of the vertebra(e). For instance if Harrington rods are placed bilaterally from L1 to L4 report a single unit of 22840 with no modifiers attached. Billing Cosurgeries Often two surgeons may work together during spinal procedures with one surgeon performing the definitive procedure (e.g. fusion) and the other placing instrumentation explains Sharon Tucker CPC president of Seminars Plus a medical coding and billing consulting company based in Fountain Valley Calif. This can complicate billing because each surgeon cannot bill for his or her individual portion of the surgery. For instance if the first surgeon files a claim for arthrodesis (22612) and the second surgeon reports instrumentation (22842) separately the second physician's claim will likely be denied because instrumentation codes cannot be billed on their own. To counter this problem both surgeons may bill as cosurgeons by appending modifier -62 (Two surgeons) to the primary procedure code (in this case 22612) advises Teresa Thompson CPC an independent coding and reimbursement specialist in Sequim Wash. Payment for the primary procedure will be increased to 125 percent of the usual value and split evenly between the two surgeons (each surgeon will receive 62.5 percent of the usual fee for the procedure). When billing as cosurgeons each physician must dictate his or her own operative report. In addition the surgeon placing the instrumentation reports the appropriate code (in this case 22842) with no modifiers attached. Per Medicare guidelines the two surgeons may also report 22842 as cosurgeons if they placed the instrumentation together. Alternatively the surgeon placing the instrumentation may bill as an assistant for the primary procedure by appending modifier -80 (Assistant surgeon) to the primary procedure code (22612) while reporting the instrumentation code (22842) with no modifiers appended. In this scenario the physician primarily responsible for the definitive procedure will receive a larger portion of the fee for that procedure. Removal Reinsertion and Post-Op Complications CPT includes several codes to describe removal and/or reinsertion of instrumentation because the instrumentation has served its purpose (the spine has healed or fused as planned) the spine has failed to fuse the patient's body has rejected the instrumentation or adjustments are needed Tucker notes. As with placement the codes describing removal correspond to the location (anterior or posterior) of the instrumentation as follows: If removal occurs after the 90-day global period of the placement procedure (for instance when the desired anatomic correction has occurred after the instrumentation has remained in place for some time) any of the above codes may be reported with no modifiers attached. However 22849-22850 and 22852-22855 are not modifier -51 exempt and therefore multiple-procedure reductions are appropriate if the removal or reinsertion occurs during the same operative session as a more definitive procedure. If a return to the operating room is necessary during the 90-day global period of another procedure because the patient's body is rejecting the instrumentation modifier -78 (Return to the operating room for a related procedure during the postoperative period) should be appended to the appropriate removal code explains Steven Hysell MD of Central California Faculty Medical Group (CCFMG) an organization of faculty physicians and staff headquartered in Fresno Calif. When instrumentation must be removed due to a failed fusion removal may be accompanied by exploration (22830 Exploration of spinal fusion). Due to national Correct Coding Initiative bundling edits however surgeons may wish to forgo reporting 22830 if significant spinal reconstruction is necessary following removal of instrumentation. Code 22830 should be reserved for those instances when exploration of spinal fusion does not require removal or further reconstruction.
Segmental posterior instrumentation attaches to the spine at three or more points, including the proximal and distal portions of the rod or other device. For instance, a rod spanning from the third cervical to third thoracic vertebra is attached at C3 and T3 but is also attached to at least one other interspace between those two points (e.g., C6/C7). Placement of segmental posterior instrumentation is described using 22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments), 22843 ( 7 to 12 vertebral segments) and 22844 ( 13 or more vertebral segments) as determined by the number of vertebral segments spanned.
Reinsertion (22849) may be necessary when a spinal fixation device fails due to breakage loosening etc. The same modifiers apply when the procedure is performed after or during the 90-day global period of another procedure as in the above situations.
Neurosurgery Coding Alert
- Receive Proper Reimbursement for Spinal Instrumentation Procedures
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