Neurosurgery Coding Alert

Question: A 52-year-old patient reports to the office complaining of three months of neck but primarily left arm pain after they lifted a heavy object. Their primary care physician recommended physical therapy, which made the patient’s condition worse. They did not respond to a cervical epidural injection. They had exam findings consistent with a left C6-C7 spondylotic ridge compressing the left C7 nerve root as demonstrated on cervical magnetic resonance imaging (MRI). Given the failure of nonoperative treatments and persistent symptoms for three months, the surgeon performed an anterior cervical discectomy with osteophytectomy using an operating microscope for microdissection at C6-C7 with structural allograft placement and anterior plate spinal instrumentation from C6-C7.

What is the correct coding for this encounter?

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Answer: On the claim, report the following:

• 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) for the arthrodesis
• +20931 (Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)) for the allograft
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)) for the instrumentation
• M47.23 (Other spondylosis with radiculopathy, cervico­thoracic region) appended to 22551, +20931, and +22845 to represent the patient’s injury

No microdissection code? While microdissection with the operating microscope was reported, CPT^® rules bundle microdissection performed during anterior cervical discectomy with/without interbody arthrodesis.