Neurosurgery Coding Alert

Anatomy, grafting are also issues when coding these repairs.

When a patient with a vertebral fracture is evaluated by the neurosurgeon, surgery may be recommended. Coding for that surgery will press the coder to make a few decisions.

Such as? How the surgeon decided whether the patient needed surgery, whether the surgery was open or closed, and in what anatomical area the surgery occurred.

Check out this rundown of the most pressing issues when coding vertebral fracture repair.

Know How Surgeon Decides to Operate

There are a number of ways the surgeon can reach the decision to operate on a patient with vertebral fracture. The road to surgery will almost always start with an evaluation and management (E/M) service. If it was an office/outpatient E/M, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.). Be observant, though; the physician might perform another E/M service — such as hospital inpatient or observation — before deciding on the procedure.

According to Penn Medicine, surgeons can use “X-rays to check for fractures or abnormal movement of the spine …spine CT [computed tomography] scan to view changes in the bone structure … and MRI [magnetic resonance imaging] scan to determine soft tissue damage to the ligaments and discs, and assess spinal cord injury.”

For spinal X-rays, look to the 72020 (Radiologic examination, spine, single view, specify level) through 72120 (Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views) codes when you report the service.

For spinal CT, look to the 72125 (Computed tomography, cervical spine; without contrast material) through 72133 (Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections) codes when you report the service.

For spinal MRI, look to the 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material) through 72158 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar) codes when you report the service.

Know What Constitutes Closed Tx

Once the decision for surgery is made, you need to know whether the surgeon performed open or closed treatment of the fractured vertebra. If the surgeon treats the fracture without making any incisions to expose the spine, then it’s a closed treatment.

You should report closed treatment with one of the following codes, depending on encounter specifics:

• 22310 (Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing)
• 22315 (Closed treatment of vertebral fracture(s) and/ or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction)

Consider this example from Gregory Przybylski, MD, MBA, Chairman of Neuroscience at the Hackensack Meridian Health Neuroscience Institute at JFK University Medical Center in Edison, New Jersey: A 72-year-old patient sustained a minor fall at home resulting in severe interscapular pain. They were evaluated in the emergency room (ER). Their neurological condition was normal. The radiologist performed thoracic radiographs, which showed a T8 compression fracture that was confirmed with noncontrast thoracic CT. Moderate-complexity medical decision making (MDM) by the neurosurgeon included assessing the patient’s history of osteoporosis, review of the imaging, and comparing various treatment options. The surgeon then performed closed treatment of the thoracic vertebral body fracture with external casting and discharged the patient home.

For this encounter, you would report:

• 22315 for the vertebral fracture repair
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) for the evaluation and management (E/M) service
• Modifier 57 (Decision for surgery) appended to 99204 to show that the decision for surgery was made during the E/M
• S22.060A (Wedge compression fracture of T7-T8 vertebra, initial encounter for closed fracture) appended to 22315 to represent the patient’s fracture

Note: The radiologist would report 72070 (Radiologic examination, spine; thoracic, 2 views) and 72128 (Computed tomography, thoracic spine; without contrast material) for the imaging services.

Know Open Tx Differences

If the surgeon uses open treatment to fix the vertebral fracture, coding will change.

“Traditionally, back surgery is performed in an open procedure in which the surgeon must get to the spine through an opening made by a large incision in the back or abdomen. However, in recent years, minimally invasive spine surgery has become the preference of both doctors and patients,” according to Nael Shanti, MD, of Shanti Spine Surgery, in a blog post.

“During standard open spine surgery, the surgeon creates a large incision (usually about six inches long) in the back and

dissects the spinal muscles to pull them away from the bone in a process called retraction. Once they visualize the bones of the spine, they will begin the necessary spinal procedure. Certain open spine surgeries require the surgeon to go in from the front through a large abdominal incision,” Shanti wrote.

Below are some of the hallmarks of open surgery; take them into account when deciding if a vertebral fracture treatment is open or closed:

• Anesthesia
• Large incisions
• Muscle retraction
• Long surgery times
• Hospitalization
• Long recovery times

Note: If the surgeon uses minimally invasive surgical techniques, coding will mirror traditional open treatment. “As long as there is direct visualization of the target, the same codes are used for an open procedure when compared with a minimally invasive procedure — the differences are the retractors used and the size of the exposure,” explains Przybylski. “For spinal fracture treatment, there are no specific minimally invasive codes other than ‘cement’ injection during vertebroplasty or kyphoplasty.”

When a patient has open surgery on a vertebral fracture, you’d represent the surgery with one of the following codes, depending on encounter specifics:

• 22318 (Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting)
• 22319 (… with grafting)
• 22325 (Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar)
• 22326 (… cervical)
• 22327 (… thoracic)
• +22328 (… each additional fractured vertebra or dislocated segment (List separately in addition to code for primary procedure))