Orthopedic Coding Alert

By Susan Callaway-Stradley, CPC, CCS-P

The coders in an orthopedic practice suffer if they don’t have a clear understanding of all of the complexities of coding spinal surgeries. In addition, the practice can suffer financially if these claims are not coded correctly.

Spinal surgeries can consist of a diskectomy, arthrodesis, grafting, and instrumentation.

1. Diskectomy. The diskectomy may be performed to remove a herniated intervertebral disk (63020-63042, laminotomy), or it may be performed only to clear the way for other procedures to be performed in that space (for example, 22554-22585, cervical, thoracic, lumbar, etc.).

2. Arthrodesis. The arthrodesis (22548-22632), or fusion procedure, is combined with a graft procedure (20930-20938). These procedures may be performed with a posterior approach, entering through the back, or with an anterior approach. The anterior approach, or access to the spine from the front, means entry must be gained by an opening on the side of the body (side of the neck for cervi-
cal repairs, and the side of the chest wall for thoracic repairs). These approaches often may require the services of a co-surgeon. (Special coding rules apply. See "How to Correctly Bill When a Diskectomy and Arthrodesis are Performed at the Same Time" on the cover of the September issue.) Sometimes the arthrodesis is performed with other procedures such as a diskectomy to reduce pressure on the spinal cord (63020-63042), or with an osteotomy (22210-22226) to reshape the vertebrae in a patient with scoliosis. When the arthrodesis is performed in conjunction with other procedures, always append a modifier -51 (multiple procedures) to the lesser-valued procedure of the two.

3. Grafting. Graft codes (20930-20938) may be

allografts or autografts, or a combination of both. The grafts may be morselized or structural, or again, a combination of both. CPT instructs the coder to choose only one graft code per operative session, so review all of the types of grafts performed during the session and bill the highest valued of those. Since a graft procedure can only be per-
formed in conjunction with other procedures, it is designated as "modifier -51 exempt" in CPT. The value for these services already takes into account the combination with other codes and is adjusted accordingly. Never append a modifier -51 (multiple procedures) to these codes, as doing so will cause additional unnecessary reduction in payment.

4. Instrumentation. Instrumentation (22840-22848) is placement of a fixation device, usually rods, along the spine to provide added stability. Instrumentation may be non-segmental or segmental. Non-segmental instrumentation is a span across any number of vertebrae that is attached at the top and bottom with no attachments in the middle. The code for posterior non-segmental instrumentation is 22840. There is no code for non-segmental anterior instrumentation. The most common segmental instrumentation is the Harrington rod, which is placed with screws along the spinal column, attached at the top, bottom and several locations along the path.

Codes for segmental instrumentation are based on the number of segments spanned. For instance, 22842 covers three to six segments, while 22843 covers seven to 12 segments, and 22844 covers 13 or more segments. Only one of these codes would be used to describe the entire span. Like grafts, instrumentation would never be coded alone, so the use of modifier -51 (multiple procedures) is not necessary. All adjustments to the value of the procedure in conjunction with other procedures have already been done.

Occasionally, along with all of the other procedures, a metal cage or other prosthetic device is placed for stabilization in an area where a large portion of the vertebra has been removed. Then the cage is usually filled with an acrylic resin called methylmethacrylate. When more than one cage is placed in the same intervertebral space at the same level, use 22851 (application of prosthetic device [eg, metal cages, methylmethacrylate] to vertebral defect or interspace) just once. When cages are placed at more than one level, indicate by number of units how many levels were treated. This code is also exempt from modifier -51, as with the grafting and instrumentation codes.

Editor’s Note: Next month, we will analyze a sample spinal surgery case covering all of these coding issues.