Neurosurgery Coding Alert

Question: A patient with cervical neuromuscular scoliosis reports to the surgeon for spinal osteotomy. The patient is placed prone on the operating table. The surgeon makes a midline posterior incision over the affected spinal area, and then retracts muscle and soft tissue to expose the vertebrae. They then remove a triangular section of bone from two segments of vertebrae, stabilize the spine using screws and rods, and use layered closure to seal the incision. The surgeon uses a posterior approach, and operates on two vertebral segments. Which osteotomy code should I use? I see there are a few to choose from.

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Answer: You should use two codes for this patient’s arthrodesis; one for the first level, which will indicate the spinal area, and another add-on code for the second level.

On the claim, report:

• 22210 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical) for the initial osteotomy
• +22216 (… each additional vertebral segment (List separately in addition to primary procedure)) for the second osteotomy
• M41.42 (Neuromuscular scoliosis, cervical region) appended to 22210 and +22216 to represent the patient’s scoliosis

Caveat: You need to be sure of the technique that the surgeon uses, as well as the area of the spine where they operate. Your code choice will depend on both variables.