Neurosurgery Coding Alert

Question: Patient underwent anterior cervical discectomy and fusion (ACDF) at C5-6 and C6-7 and hemi-corpectomy with spinal decompression at C6. The operative note reads as under:

"The C6-7 level was approached. This level had more severe stenosis, significant cord signal changes, and substantial disk-osteophyte complex. The annulus was incised with a #15 blade and the anterior osteophytes removed, gaining access to the disk space. Anterior two-thirds of the disk material was removed with straight and angle curets and pituitary rongeurs. Going posteriorly, remaining disk material was also removed. The significant disk-osteophyte complex noted was difficult to remove without performing additional hemi-corpectomy. Therefore, a hemi-corpectomy of C6 was done for improved exposure of C6-7 level and then posterior osteophytes at both C6 and C7 were removed. The hemi-corpectomy of C6 was completed and all posterior osteophytes were removed using diamond-tipped burr and #1 curet. Posterior longitudinal ligament was also taken down with adequate endplate preparation and spinal cord decompression." Can this be billed as 63081?

Ohio Subscriber

Answer: If your surgeon removed at least 50% of the C6 vertebral body, you may report 63081 (Vertebral corpectomy [vertebral body resection], partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment), 22554(Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2) -51 (Multiple Procedures:...), +22585 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression); each additional interspace (List separately in addition to code for primary procedure]). The diskectomies at C5-6 and C6-7 are included in the C6 corpectomy.

If he did not remove the minimum 50% of C6 then you would code 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2), +22552 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace [List separately in addition to code for separate procedure]). Additionally, you report the hardware/graft codes.