Neurosurgery Coding Alert

You must document every step to gain full payment for this multi-code procedure

To report an anterior cervical diskectomy with fusion (ACDF) accurately, make sure that the documentation distinguishes minimal diskectomy, which is part of the arthrodesis, from an extensive diskectomy with decompression as required for ACDF.

What is ACDF? ACDF consists of three basic steps, explains Kee D. Kim, MD, associate professor of neurosurgery at University of California, Davis in Sacramento.

1). The surgeon approaches the cervical spine through an incision in the front of the neck to remove disks and/or bone spurs that may be compressing the spinal cord and/or nerve root (diskectomy with decompression). The surgeon typically removes bone from around the area of the excised disk and then;
2.) places bone grafts to stabilize the spine, and;
3.) fuses the adjacent vertebrae, often also using titanium plating (instrumentation).

When reporting arthrodesis (22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2) and diskectomy (63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) during the same operative session, you must indicate that the surgeon performed an extensive diskectomy to receive separate payment for 63075, says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater, Fla.

Insurers often reduce or deny claims for 63075 during ACDF because the descriptor for 22554 specifically includes minimal diskectomy to prepare the interspace. Therefore, your documentation must clearly support 63075 by describing the surgeon's decompression of the neural elements and removal of 1.) any fibrovascular scar tissue over the dura; 2.) any disk material on the far lateral sides; and 3.) any osteophytes (bone spurs) that may be present, Allen stresses.

Appeal if you have to: If you receive a rejection for a properly documented diskectomy with decompression (63075) and fusion (22554), be sure to contact the payer and explain that the services are distinct and deserve separate payment. Many carriers have set up computer edits to catch and reject certain coding combinations. These edits cannot determine the extent of the services the surgeon provided, and consequently, some legitimate claims (including many ACDF claims) suffer rejection.

Rely on -59: To further support your coding, you may append modifier -59 (Distinct procedural service) to 63075 to further differentiate it from 22554.

If the surgeon performs fusion and/or diskectomy at more than one interspace, you should account for the additional level by reporting add-on codes +22585 (Arthrodesis,... each additional interspace [List separately in addition to code for primary procedure]) and +63076 (Diskectomy... cervical, each additional interspace [List separately in addition to code for primary procedure]) as appropriate, Allen says.

Example: The surgeon performs diskectomy with nerve decompression and removal of bone spurs at interspaces C3/C4 and C4/C5, followed by fusion at both levels. You would report 63075 for diskectomy at the initial interspace and 63076 for the second interspace. Likewise, you should claim 22554 for fusion at the first level and 22585 for fusion at the subsequent level.

Remember: You don't need modifiers for add-on codes. The CPT code descriptors for add-on codes define these procedures as "in addition to code for primary procedure," and therefore multiple-procedure rules do not apply, explains Alice Church, CCS-P, coding and reimbursement analyst for Wolcott, Wood & Taylor Inc. and chief billing officer for the University of Illinois Hospital Physicians in Chicago.

Tip: Don't bill separately for operating microscope. Surgeons often employ an operating microscope during diskectomy with decompression, Kim says. You should not, however, report +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) in addition to 63075/+63076. CPT defines use of the operating microscope as an inclusive component of diskectomy.

Finally, you should report bone grafts independently of arthrodesis. Neither CPTnor CMS bundles arthrodesis and bone graft. Generally, surgeons will place one of two types of bone grafts during ACDF: