Neurosurgery Coding Alert

Question: My neurosurgeon performed a posterior lumbar interbody fusion (PLIF) with a discectomy. He used a structural iliac crest autograft for fusion at L4/L5 and L5/S1 interspaces. Which CPT^® codes should I report for this procedure?

Montana Subscriber

Answer: You should report 22630 for the L4/L5 interspace and +22632 for the additional L5/S1 interspace. The discectomy is considered an inclusive service to the interbody fusion at both levels and is not separately reportable. The structural iliac crest autograft would be reported once with +20938 (Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)) for both levels.

PLIF explained: For a standard PLIF procedure, because of the surgeon’s posterior approach, you should report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar).

Code +22632: Code +22632 (Arthrodesis, posterior interbody technique, including laminectomy and/ or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)) is an add-on code you report in conjunction with 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)); 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar) or 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 and segment; lumbar) when performed at a different level, according to CPT^®.

Coding tip: When the surgeon performs a posterior interbody fusion arthrodesis at an additional level without concurrent posterolateral fusion, report +22632.