Orthopedic Coding Alert

Can you make all the right moves to code this clinical scenario?

Patients reporting to the orthopedist with cervical disc disorders can create coding confusion that is difficult to untangle. Once the provider figures out the patient’s condition, she’ll have to decide on a course of treatment.

Getting to the bottom of these claims can be difficult, especially since they’ll almost certainly involve multiple codes, and could include more than one visit to the orthopedist.

Help’s here: Check out this detailed clinical scenario, courtesy of Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois. It involves a patient who eventually undergoes anterior cervical discectomy and fusion (ACDF) for a cervical disc disorder.

The Case

Encounter 1: A new patient reports to the orthopedist complaining of pain shoulder blade and down the left arm, with numbness and tingling in the thumb and index finger. A three-view X-ray of the cervical spine shows narrowing in the C4-C5 area. The orthopedist then performs a magnetic resonance imaging (MRI) of the cervical spine without contrast. The orthopedist prescribes the patient a DosePack and gives an order for physical therapy two to three times a week for four weeks. (The physical therapy occurs at a different provider’s office). Notes indicate a level-two evaluation and management (E/M) service occurred during the encounter.

Encounter 2: The patient returns to the orthopedist five weeks later, saying that the physical therapy was not helping. A repeat MRI without contrast shows disc herniation at C4-C5. The orthopedist schedules surgery and prescribes medication. Notes indicate a level-four E/M service.

Encounter 3: The orthopedist performs ACDF at C4-C5 with cage insertion, non-segmental instrumentation, and bone morphogenetic protein (BMP). Encounter notes indicate that the plate and screws (anterior instrumentation) are a separate implant and not components of a standalone interbody device.

The Coding

Encounter 1: You should report:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making …) for the E/M service;
• 72040 (Radiologic examination, spine, cervical; 2 or 3 views) for the X-ray; and
• 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material) for the MRI.

Encounter 2: You should report:

• 72141 for the MRI; and
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …) for the E/M with modifier 57 (Decision for surgery) attached to show that the E/M led the orthopedist to schedule surgery.

Encounter 3: You should report:

• 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) for the ACDF;
• +22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)) for the cage insertion;
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)) for the non-segmental instrumentation; and »
• +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)) for the BMP.