Neurosurgery Coding Alert

Question: A 25-year-old snowboarder accidentally encounters an obstacle, resulting in a serious fall. Severe neck pain accompanied by transient paralysis and persistent arm paresthesias prompted the ski patrol to send them to the local ED. Plain radiographs showed a unilateral C67 facet fracture with dislocation, which was confirmed on cervical CT and magnetic resonance imaging (MRI). A spine surgeon evaluated the patient and found no spinal cord injury, but neurological evidence of unilateral triceps weakness. Recommendation for open treatment of the fracture dislocation was given. A posterior open cervical treatment was performed with reduction of the fracture, decompression of the C7 nerve root and posterior C67 arthrodesis with local bone graft and non-segmental posterior C67 spinal instrumentation. The patient was admitted to the hospital and discharged the following morning.

How should I report this encounter?

Oregon Subscriber

Answer: For this encounter, you would report:

• 22326 (Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical) for the fracture repair
• +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 the instrumentation
• 22600 (Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment) for the arthrodesis
• Modifier 51 (Multiple procedures) appended to 22600 to show that the surgeon performed multiple procedures
• +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)) for the autograft
• 99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.) for the inpatient evaluation and management (E/M) service
• Modifier 57 (Decision for surgery) appended to 99223 to show that the inpatient E/M led to the decision for surgery
• S12.500A (Unspecified displaced fracture of sixth cervical vertebra, initial encounter for closed fracture) appended to 22326, +22840, 22600, +20936, and 99223 to represent the patient’s C67 fractured vertebra
• S13.171A (Dislocation of C6/C7 cervical vertebrae, initial encounter) appended to 22326, +22840, 22600, +20936, and 99223 to represent the patient’s C67 dislocation
• E88.54 (Accidental fall from snowboard) appended to 22326, +22840, 22600, +20936, and 99223 to represent the cause of the patient’s injury

Note: The radiologist would report 72050 (Radiologic examination, spine, cervical; 4 or 5 views) and 72125 (Computed tomography, cervical spine; without contrast material).