Neurosurgery Coding Alert

Question: Our surgeon performed the following procedures:

1) Hardware removal with fusion exploration, L3-L5.

2) Redo posterolateral fusion using a combination of local bone as well as Grafton demineralized bone matrix (DBM) from L3-L5.

3) Right L2-L3 decompression for spinal stenosis.

4) Right L2-L3 transforaminal lumbar interbody fusion using K2 PEEK interbody device and local bone and DBM.

5) Instrumentation from L2-L5 using the K2 Mesa System.

6) Neuromonitoring.

This was reported with codes:

• 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]);
• 22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]);
• 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar);
• 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar);
• 22830 (Exploration of spinal fusion);
• 22842 (Posterior segmental instrumentation [eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure]);
• 22851 (Application of intervertebral biomechanical device[s] [eg, synthetic cage[s], methylmethacrylate] to vertebral defect or interspace [List separately in addition to code for primary procedure]);
• 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]).

Should the surgeon have used 22849 (Reinsertion of spinal fixation device) instead of 22830 and 22842 because of the redo? And what about the extension of the fusion? Should we code separate instrumentation for it or is that also included in the 22849?

Ohio Subscriberr

Answer: The primary procedures performed were the posterolateral arthrodesis from L3-L5, reported as 22612 and 22614, and the posterior lumbar interbody arthrodesis at L2-3, reported as 22630-51 (Multiple Procedures:...).

The exploration of fusion code 22830 would not be reported, since an arthrodesis was performed at the levels of exploration and would be considered bundled with the arthrodesis. Only if an arthrodesis was not performed would the exploration of fusion code be appropriately reported. You may wish to check the operative note to determine whether posterolateral arthrodesis was also performed at L2-3, which if performed, would be reported with an additional unit of 22614.

The decompression code 63047 is also considered bundled with 22630 under most circumstances. Unless the surgeon documents the additional bony work necessary beyond that required to perform the transforaminal interbody fusion (which includes laminectomy, facetectomy, and discectomy), code 63047 would not be reported separately. Given that the decompression and interbody fusion were both performed on the right at L2-3, the decompression is most likely bundled into 22630.

The bone graft code 20936 and code 22851 for placement of an interbody prosthetic device at L2-3 are appropriate.

Finally, one may report either 22842 or 22849-51, but not both. Since pedicle screw instrumentation is placed from L2 to L5, the segmental instrumentation code 22842 is most accurate. There is a balance between the additional work in removing the instrumentation and the ease of replacing pedicle screws at L3-L5 using the same holes and trajectories. Neuromonitoring would not be separately reportable by the surgeon.