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Neurosurgery Coding Alert

Want to Give Your Bilateral Spinal Surgery Claims Backbone? Turn to Modifier -50

Published on Thu Sep 11, 2003

If your spine surgeon performs bilateral surgeries such as lumbar laminotomies (63030), you should append modifier -50 (Bilateral procedure) to the procedure code and double the charges rather than reporting multiple units. Coders who follow this rule will be well prepared to report complex procedures, such as bilateral laminotomies, on several levels.
 
Because 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]) refers to "one interspace," CPT directs surgeons to bill each additional interspace (a vertebral interspace is the nonbony compartment between two adjacent vertebral bodies) beyond the first using +63035 (... each additional interspace, cervical or lumbar [list separately in addition to code for primary procedure]).
 
"Our surgeon performed bilateral laminotomies on two levels, so we billed [a commercial payer] 63030 on one line and 63030-50 on the next, followed by two units of 63035," says Stacey Kriser, billing administrator at Spine Associates PC in Minneapolis. "We got paid much less than expected, though, because they saw that both line items of 63035 referred to the same spinal level, so they disallowed the second unit. Later we learned that we could also bill 63035 bilaterally."
 
You should bill lumbar laminotomies performed bilaterally on four levels as follows, says Annette Grady, CPC, CPC-H, director of reimbursement at the Bone and Joint Center in North Dakota and the chairwoman for the North American Spine Society's administrative task force:

 

  • 63030-50 (for the first level - double your fee)
     
  • 63035-50 x 3 (for the additional three levels).

    Place the "3" in the claim form's "units" field, and increase your fee because each unit is bilateral. Grady says that this is the correct billing method for CMS and many Blue Cross carriers, but you should always check with your workers' compensation and commercial carriers to confirm how they prefer bilateral procedures to be reported.
     
    "On your claim form, indicate the levels that the surgeon addressed, or send along the operative report," Grady says. "Unless the surgeon actually uses the word 'bilateral' in his notes, always double-check to determine whether he addressed each level bilaterally."
     
    If the surgeon performs four unilateral levels of laminotomy, you would report 63030 with either modifier -LT (Left side) or -RT (Right side) to indicate the side the surgeon addressed, and 63035 x 3 (with the -LT or -RT modifier appended), Grady says.

    Know Your Anatomy for Arthrodesis

    Suppose the surgeon's notes indicate anterior fusion of L1 to L3. Many coders are tempted to bill one unit of 22558 (Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; lumbar) and two units of +22585 (... each additional interspace [list separately in addition to code for primary procedure]), thus totaling three spinal levels.
     
    Instead, you should report one unit of 22558 with just one unit of 22585 because L1-L2 is one interspace and L2-L3 is another, Grady says. In this situation, knowing your anatomy is very important, she says. Although L1, L2 and L3 constitute three vertebral bodies, the surgery  addresses only two interspaces. The interbody fusions are reported per interspace.
     
    You should code other types of spinal surgeries, such as osteotomies (22210-22226), according to vertebral segments, not interspaces. Therefore, osteotomies to L1, L2 and L3 would warrant billing one unit of 22214 (Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; lumbar) and two units of +22216 (... each additional vertebral segment [list separately in addition to primary procedure]).
     
    "The descriptor usually refers to either a vertebral segment or an interspace," Kriser says. "So as long as you pay attention to the code definitions, you should be able to determine how many units of the code to bill."

    Skip Modifiers With Instrumentation

    Report spinal instrumentation insertion in addition to the primary arthrodesis procedure, but do not append modifier -59 (Distinct procedural service) or -51 (Multiple procedures). Spinal instrumentation (22840-22848 and 22851) refers to rods, screws, hooks, cages and synthetic bone materials that provide stability and often hold the spinal column together.
     
    "These modifiers would cause a payment reduction or complete denial and are not necessary with the instrumentation codes," Grady says. "These codes should be paid at 100 percent, so report them on separate line items after the corresponding arthrodesis codes."

    Ask Each Carrier for Its Guidelines

    "There is so much controversy surrounding spine surgery coding because carrier requirements vary," Grady says. "When you're starting out with a carrier, ask them how they prefer you to code the various spine surgeries. Some insurers (such as Medicare) request bilateral modifiers on a single line, some want separate line items, some want site modifiers, and so on."

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