Neurosurgery Coding Alert

Do you know which add-ons go with which arthrodesis types?

Coding for arthrodesis poses a lot of challenges for coders in neurosurgery practices.

Examples: There are different codes for different types of arthrodesis, and you have a lot of choices. This means that you’ll need to know the specifics on several different types of arthrodesis surgeries. Also, you’ll need to choose the proper add-on codes, at the appropriate times. The add-ons you use for arthrodesis claims will depend on the type of arthrodesis the surgeon is performing, so you must know which codes go with which add-ons.

Check out this advice from Jessica Miller, MHA, CPC, VP revenue cycle at Ortmann Healthcare Consulting Services in South Carolina

Use This Guide to Arthrodesis Definitions, Types

Arthrodesis can be performed across many joints in many parts of the anatomy. For the purposes of this story, however, we’ll focus on the most frequent spinal arthrodesis codes you’re likely to encounter.

Definition: Also known as spinal fusion, spinal arthrodesis is a surgery to permanently join two Vertebrae (the interlocking bones of the spine) across the joint between them. The surgeon applies bone graft material to fuse the spine at the front, side or the back of the vertebrae or some combination after disrupting the joint. The procedure helps to alleviate persistent pain caused by various spinal conditions, including herniated intervertebral disks, stenosis, or spinal injuries.

According to Miller, you’ll be breaking arthrodesis claims down among five different types of arthrodesis.

Each of the following types has its own codes and rules for reporting:

• Lateral extracavitary
• Anterior
• Posterior/posterolateral
• Posterior interbody
• Combined interbody/posterolateral

Report Discectomy, if Performed, With Lateral Extracavitary

During lateral extracavitary arthrodesis, the surgeon “accesses the vertebra in a lateral extracavitary approach to obtain a wider view. [They] remove some of the cartilage cushion, or disk material, from between the vertebrae to prepare the bony surfaces for fusion,” reports Codify.

Keep in mind that the lateral extracavitary approach is performed through a posterior incision, mobilizing the paraspinal muscles to allow a nearly direct lateral view from the initially posterior approach in the thoracic or lumbar spine. These codes should not be applied to direct lateral approaches to the thoracic or lumbar spine, which are correctly reported with anterior arthrodesis codes.

Miller said to use the following codes to report lateral extracavitary arthrodesis:

• 22532 (Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic)
• 22533 (… lumbar)
• +22534 (Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure))

In all levels, report additional add-ons for grafts and instrumentation, if used. For example:

• Use +20936 (Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)), +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)), and +20931 (Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)) for bone grafts.
• Use +22840 (Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)) for instrumentation.

If multiple levels of arthrodesis are performed, then segmental spinal instrumentation may be reported with +22842. Although less common, because a lateral view is achieved with this approach, anterior spinal instrumentation may sometime be concurrently performed and reported with +22845.

Split Anterior Arthrodesis Into These Types

Anterior arthrodesis procedures break into two main types: anterior interbody and anterior cervical discectomy and fusion (ACDF).

The difference: Anterior interbody arthrodesis involves a surgical incision in the front or side of the body with removal of disk material solely for the purpose of disrupting the joint for fusion. Anterior interbody arthrodesis codes do not include a direct decompression of nerve(s) and/or spinal cord. In ACDF, “A cervical disc is removed through the front of the neck with decompression of the spinal cord and/or nerve root(s) to help ease radicular pain and related symptoms. Fusion is performed to stabilize the vertebrae,” reports Codify by AAPC.

Miller said to use the following codes to report anterior interbody arthrodesis:

• 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2)
• 22556 (… thoracic)
• 22558 (… lumbar)
• +22585 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure))

Also, ACDF uses the following codes:

• 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2)
• +22552 (… cervical below C2, each additional interspace (List separately in addition to code for primary procedure))

Add-on alert: For anterior interbody arthrodesis and ACDF, Miller said you’ll report the following add-ons when appropriate:

• +22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)), +20930, +20931 (Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)), +20936 for on-lay local autograft, and +20938 for structural interbody autograft
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)) for instrumentation

Look for ‘Back,” ‘Side,” in Posterior/Posterolateral Notes

During a posterior/posterolateral arthrodesis, the surgeon “applies bone graft material to fuse the spine at the back of the vertebrae or at the back and side,” per Codify.

Miller said to use the following codes to report posterior/ posterolateral arthrodesis:

• 22600 (Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment)
• 22610 (… thoracic (with lateral transverse technique, when performed))
• 22612 (… lumbar (with lateral transverse technique, when performed))
• +22614 (Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure))

Also, use the following add-ons as appropriate:

+20930 and +20936 for bone grafts

+22840 and +22842 (Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)) for instrumentation

Laminectomy Marks Posterior Interbody Arthrodesis

During posterior interbody arthrodesis, the surgeon “excises the lamina and disk material and applies bone graft between the disks to fuse them,” reports Codify.

Miller said to use the following codes to report posterior interbody arthrodesis:

• 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar)
• +22632 (… each additional interspace (List separately in addition to code for primary procedure))

Also, use these add-ons as appropriate:

• +22853, +20930, +20931, and/or +20938 for biomechanical devices and grafts
• +22840 and +22842 for instrumentation

Multiple Approaches Could Mean Interbody/Posterolateral

During combined interbody/posterolateral arthrodesis, “the provider joins two adjoining lumbar vertebral bodies permanently by accessing the operative site with a combination of approaches trying to achieve a better outcome of surgery,” reports Codify.

Miller said to use the following codes to report interbody/ posterolateral arthrodesis:

• 22633 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace; lumbar)
• +22634 (… each additional interspace and segment (List separately in addition to code for primary procedure))

Also, report these add-ons as appropriate:

+22853, +20930, +20931, and +20938 for biomechanical devices and grafts +22840 and +22842 for instrumentation.