Neurosurgery Coding Alert

Tip: Type of graft determines 22851 vs. 20931

If conflicting information on how to report allograft procedures is making you question when you should use code 22851, look no further. We-ll explain the cause of confusion and the correct way to report these procedures.

Neurosurgery Coding Alert experts advised in the December 2005 issue that you should report 22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace) for a Cornerstone fibular allograft bone plug or bone spacer. But one of our subscribers, Ronda Tews, CPC, CCP, a compliance project manager for St. John's Health System in Springfield, Mo., says that physicians and coding consultants have told her not to use 22851 for the Cornerstone graft.

Solution: Neurosurgery Coding Alert went back to our sources to verify whether you can report 22851 with a -Cornerstone graft.- The answer is that you should use 20931 (Allograft for spine surgery only; structural) for the Cornerstone SR allograft series, and use 22851 only for the Verte-Stack Cornerstone spacers made of metal or PEEK.

Threaded Bone Dowels Lead to 22851

To successfully choose the correct CPT procedure code when your neurosurgeon places an allograft, you-ll need to look closely at the op report. The type of graft your physician used will lead you to the code you should submit.

You have three code choices when your neurosurgeon places an allograft:

- 20930--Allograft for spine surgery only; morselized
- 20931--... structural
- 22851--Application of intervertebral biomechanical device(s) (e.g., synthetic cage[s], threaded bone dowel[s], methylmethacrylate) to vertebral defect or interspace.

Your neurosurgeon may use several types of structural allografts, and the words he uses in his documentation will help you decide which code is appropriate. The different terms you may see are VG2 bone graft, interbody spacer, Cornerstone graft, mechanical spacer, Brantigan cages, VG2 allograft, Pyramesh cage, Pyramid ovoid mesh, PEEK cages, allograft interbody spinal implants, Osteotech interbody spacer, VG2 lordotic spacer, Medtronic Verte-Stack Cornerstone, Harms cage and titanium mesh vertebral body replacement, Tews says.

The procedures in which the neurosurgeon places the allograft versus the metal or PEEK spacer are not very different, says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery in New York.

In the February 2005 CPT Assistant, the American Medical Association clarified that the only allograft that qualifies for code 22851 is threaded-bone dowels. -All other bone allografts are structural allografts and should be reported with CPT code 20931,- the article explains. You should use code 20930 for any morselized allografts.

Note: You should also report 22851 when the neurosurgeon places a cage, the ovoid mesh, or the titanium mesh, Tews says.

Example: A patient with C5-C6 degenerative cervical disk disease (722.4, Degeneration of cervical intervertebral disk) presents to your practice. The neurosurgeon performs anterior interbody fusion at that level with minimal diskectomy (without decompression), and places a Cornerstone fibular allograft and plate.
 
In this scenario, report 22554 (Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2) for the fusion and diskectomy. Then, report 20931 and 22845 (Anterior instrumentation; 2 to 3 vertebral segments) for the placement of the allograft and plate. Note that the last two codes are modifier 51 exempt codes, and you can report them together without adding modifiers.

By Level or by Case?

The other difference between reporting 20931 and 22851 is how many times you can report the code. Medicare guidelines state that you should report 20931 only once per surgery.
 
You can report 22851 once for each level, however. But even if the neurosurgeon places more than one threaded bone dowel at a particular level, you should still report the code just once for that interspace. For instance, if the surgeon places two cages or three bone dowels at interspace T11/T12, you should report a single unit of 22851.

You may report additional units of 22851 for additional interspaces the neurosurgeon treats. For example, if the surgeon places two cages at T11/T12 and a third cage at T12/L1, you should report 22851 x 2.

Tip: For some payers, you may have to append modifier 59 (Distinct procedural service) to the second unit of 22851 to indicate that it represents instrumentation placed at a separate anatomic location.
Changes May Be on the Horizon

Don't think you-re the only one confused about why the threaded bone dowel allografts should be coded differently than other graft placements. Coding professionals have contacted the AMA and requested a review of these coding guidelines.

-It's likely that they-ve based their request on the fact that there's not too much difference between this shaped allograft and a threaded bone dowel,- Sandhusen says. -One is impacted into place, and the other is twisted. There is even less difference, in terms of work, between a PEEK graft and a Cornerstone allograft; both are removed from their package and inserted between the vertebrae, although additional contouring is often done on the allografts.-

Watch for clarifications or changes in how to code these procedures. Neurosurgery Coding Alert will keep you updated if the AMA addresses this topic in the future.