Neurosurgery Coding Alert

Do you know which procedure is for spinal realignment?

Two surgical procedures your provider might perform are vertebral excision and osteotomy. Though both surgeries may deal with similar components of the spine, they are different for coding purposes.

How? There are different codes for the surgeries, as well as add-on codes to consider. If you don’t know what you’re doing, things can get confusing fast.

During her presentation “Coding for Spine Procedures” at HEALTHCON 2022, Deni Adams, CPC, CPB, CPPM, CEMC, broke down the differences between vertebral excision and osteotomy. Here’s a bit of the knowledge she passed on.

Know Excision/Osteotomy Differences

The first thing you’ll need to know is how to differentiate between an excision and an osteotomy.

Excision: “The provider excises a portion of …a vertebra to remove a bony lesion, or diseased area, contained within that single bone,” according to Codify by AAPC.

Osteotomy: According to CPT^® 2022, “Spinal osteotomy procedures are reported when a portion(s) of the vertebral segment(s) is cut and removed in preparation for re-aligning the spine as part of a spinal deformity correction.”

Excision Can Be Posterior, Anterior

There are two types of vertebral excision, Adams pointed out.

Posterior excision occurs when the provider removes part of the back part of a cervical, thoracic, or lumbar vertebra to remove a bony lesion or a diseased vertebral portion.

Depending on anatomy (cervical, thoracic, lumbar) and number of segments treated, code posterior excisions with 22100 (Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical) through +22103 (… each additional segment (List separately in addition to code for primary procedure)).

Anterior excision occurs when the surgeon removes parts of the vertebral body of a cervical, thoracic, or lumbar vertebra to remove a damaged or diseased area. During anterior excision, the provider does not decompress the spinal cord or nerve roots.

Depending on anatomy (cervical, thoracic, lumbar) and number of segments treated, code anterior excisions with 22110 (Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical) through +22116 (… each additional vertebral segment (List separately in addition to code for primary procedure))

Modifier alert: Surgeons often work in tandem on these excisions; so much so, in fact, that CPT^® features special guidance on how to handle co-surgery situations in its manual. “For the following codes, when two surgeons work together as primary surgeons performing distinct part(s) of partial vertebral body excision, each surgeon should report his/her distinct operative work by appending modifier 62 [Two surgeons]to the procedure code.” You’re allowed to report any of the above vertebral excision codes with modifier 62 — “as long as both surgeons continue to work together as primary surgeons,” CPT^® explains. Also, make sure you apply modifier 62 to only one primary procedure and its associated add-on levels.

Osteotomy Marked by Spinal Realignment

While there are two different vertebral excision approaches, there are three osteotomy types among the anterior and posterior approaches that you’ll likely be coding for, Adams pointed out.

Pedicle/vertebral body subtraction occurs when the surgeon removes portions of a thoracic or lumbar vertebra to correct kyphosis. The surgeon performs osteotomy with a three-column approach and removes bone from all three vertebral columns, according to Codify by AAPC.

Surgical breakdown: The posterior column is comprised of the pedicles, facet joints, laminae and spinous process. The middle column is comprised of the posterior third of the vertebral body and intervertebral disc, while the anterior column is comprised of the anterior two-thirds of the vertebral body and intervertebral disc.

The surgeon typically uses an osteotome and/or drill to remove bone/disc from all three vertebral columns, realigning the spinal column and correcting abnormal curvatures in the thoracic and/or lumbar area(s) of the spine. While a single interspace pedicle subtraction osteotomy is more common, occasionally a severe deformity may require more than one interspace level to be treated in order to achieve satisfactory deformity correction.

Depending on anatomy (thoracic, lumbar) and number of segments treated, you’ll code pedicle/vertebral body subtractions with 22206 (Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic) through +22208 (… each additional vertebral segment (List separately in addition to code for primary procedure)).

Start at 22210 for Posterior Osteotomy

Posterior column osteotomy occurs when “the provider incises a vertebra, one of the interlocking bones in the spine, to remove portions of the bone, changing the alignment of the spinal column. This corrects an abnormal curvature in the cervical spine, or neck area,” according to Codify by AAPC. This vertebral incision is called osteotomy, or sometimes “bony incision.”

Since the posterior column resected is comprised of the facets and laminae, this osteotomy removes less bone and therefore only allows a smaller degree of correction when compared with the three-column osteotomy. This type of osteotomy is sometimes called a Smith-Peterson osteotomy. It would be more common to report multiple levels of a posterior osteotomy given the smaller correction afforded when compared with the three-column technique.

Because both posterior types of osteotomies involve bone removal, a decompression code such as laminectomy would not be separately reportable at the same interspace level.

Depending on anatomy (cervical, thoracic, lumbar) and number of segments treated, you’ll code these surgeries with 22210 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical) through +22216 (… each additional vertebral segment (List separately in addition to primary procedure)).

22220-+22226 Marks Anterior Osteotomies

Anterior body osteotomy occurs when the provider incises a cervical/thoracic/lumbar intervertebral space to change spinal alignment. The surgeon will also remove the disk material adjoining the vertebra. This corrects an abnormal curvature in the cervical/thoracic/lumbar area or mobilizes an arthrosed joint to allow for deformity correction.

Depending on anatomy (cervical, thoracic, lumbar) and number of segments treated, you’ll code anterior column osteotomies with 22220 (Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical) through +22226 (… each additional vertebral segment (List separately in addition to code for primary procedure)).

Because anterior osteotomy includes bone and intervertebral disc removal, a decompression code such as discectomy would not be separately reportable at the same interspace level. Similarly, one would not report an anterior cervical osteotomy (22220) with an anterior cervical discectomy and fusion (22551 [Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2]).