Orthopedic Coding Alert

This month, we will analyze a spinal surgery that includes arthrodesis (fusion), diskectomy, and instrumentation. This case was submitted for study because many of the procedures had been denied when submitted to the insurance company.

Procedure: Reconstruction of L1 vertebral body, spine fusion with autogenous grafting and instrumentation for scoliosis.

Diagnosis: Malunited fracture, L1, idiopathic scoliosis.

Codes billed: 22810, 63077, 22222, 22846, 20936, 22226, 22226, 22226 and 20937.

Operative procedures: The patient was placed on the left side in preparation for an anterior approach. The abdomen was entered at the area of the ninth rib.

The initial graft was obtained (20936, autograft for spine surgery only [includes harvesting the graft]; local [ribs, spinous process, or laminar fragments] obtained from the same incision). The ninth rib was removed and retained for grafting material during the arthrodesis. The vertebral bodies between T11 and L3 were exposed.

The old tissue from the previous fracture was removed and the vertebral bodies reshaped where necessary: (22222, osteotomy of spine, including diskectomy, anterior approach, single vertebral segment; thoracic and 22226, each additional vertebral segment [List separately in addition to code for primary procedure]).

The disk spaces of T11-T12, T-12-L1, L1-L2, L2-L3 were excised with a combination of sharp blade dissection, curettes, and rongeurs, exposing the cancellous and cortical surfaces of the endplates. The body of L1 was seen to contain a 1.4-cm to 2.0-cm irregular oval-shaped defect in its proximal surface and a little bit on its caudad surface, where scar tissue from the old fracture was present. This tissue was removed leaving a small defect. There was no nonunion but there was substantial soft tissue defect. The cortical rim was intact. The vertebra were somewhat wedge-shaped.

Next, the fusion was accomplished and the instrumentation placed for stability (22810, arthrodesis, anterior, for spinal deformity, with or without cast, 4 to 7 vertebral segments and 22846, anterior instrumentation; 4 to 7 vertebral segments).

After all the disks were removed and the endplates exposed, the ninth rib was cut up into small pieces. The instrumentation was then placed using premeasured Moss-Miami screws inserted through the bodies of L3, L2, L1, T11, and T12. A rod was contoured, inserted in the screw heads and fastened with the fastening screws. The rod was rotated and locked into place. The endplates were fish-scaled prior to putting in the bone graft, and then the bone graft was placed into the prepared endplate disk spaces. Beginning at L2-L3, the disk space was closed after it had been packed with bone by compressing the screws and locking. The same procedure was done up to T11-T12. At L1 we packed the defect that had been created.

An additional [...]