Neurosurgery Coding Alert

Question: In a patient diagnosed with 'platybasia with occipitocervical instablity', our surgeon did the following procedure: "Occipito-cervical fusion (pedicle screws and rods) - occiput to C2, C3, C4 with laminectomy C2, C3, C4, posterior foramen magnum resection, decompression of brainstem and spine at the craniocervical junction."What are the correct codes we can report?

California Subscriber

Answer: You report the resection of the posterior foramen magnum and decompression of brainstem and spine with 61343 (Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft [eg, Arnold-Chiari malformation]). Also include codes 22590 (Arthrodesis, posterior technique, craniocervical [occiput-C2]) for the occipitocervical fusion from the occiput to C2, 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment) -51 (Multiple procedures) for C2-3 and 22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) for C3-4. You report the posterior instrumentation with the segmental posterior instrumentation code 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]). You may report bone graft harvest and spinal navigation separately, if performed.