Orthopedic Coding Alert

Multiple procedures or spinal levels may merit modifiers, but not always

When your orthopedic surgeon performs two or more distinct procedures or services on the same patient on the same day, chances are you'll need a modifier.
 
Take our quiz to determine whether you know when to append -25, -51 and -59 to your spinal procedure claims.

Do Separate Rules Apply to Separate Vertebrae?

Scenario #1: The surgeon performs posterior interbody fusion at L1/L2 (22630, Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar), followed by laminectomy at L4 (63047, Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar).

Should you choose modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), -51 (Multiple procedures) or -59 (Distinct procedural service)?

Solution #1: You should report 22630, 63047-59, says Jay Neal, an independent billing and coding consultant in Atlanta. "Some coders might quickly glance at CPT and assume that 63047 is not billable in this instance, but when you dig deeper, you'll see that you can report both codes."

CPT specifies that 22630 includes laminectomy and/or diskectomy to prepare the interspace for posterior lumbar interbody fusion, and the National Correct Coding Initiative bundles 63047 into 22630.

However, the two procedures in our example occur at separate anatomic locations. Therefore, you can append modifier -59 to collect separate payment for the
patient's laminectomy.

Should You Append -51 to Add-On Codes?

Scenario #2: The surgeon performs arthrodesis at three levels: C3-C4 (22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2), C4-C5 and C5-C6 (2 x +22585, ... each additional interspace [list separately in addition to code for primary procedure]).

Should you choose modifier -25, -51 or -59?

Solution #2: Trick question: In this case, you shouldn't need a modifier. Although this is a "multiple procedure" surgery, code 22585 is an add-on code and is, therefore, modifier -51 exempt, says Heather Corcoran, coding manager at CGH Billing Services, a medical billing firm in Louisville, Ky.

Caveat: Some payers may deny the subsequent line item of 22585 because their computer system classifies it as a "duplicate." If your payer has a history of such denials, you should append modifier -59 to the second listing of 22585.

Does -25 Apply to Consults?

Scenario #3: A patient complaining of lower back pain presents to the orthopedic surgeon at the request of his primary-care physician. During the consult examination (99243, Office consultation for a new or established patient ...), the surgeon administers an epidural steroid injection (64475, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level).
 
Should you choose modifier -25, -51 or -59?

Solution #3: Because the physician performed an E/M service and a procedure on the same day, you should append modifier -25 to the E/M service code, as follows: 64475, 99243-25, Corcoran says.

Should You Append -51 for Multiple Levels?

Scenario #4: The orthopedic surgeon removes two lower thoracic vertebrae (63087, Vertebral corpectomy [vertebral body resection], partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root[s], lower thoracic or lumbar; single segment; and +63088, ... each additional segment [list separately in addition to code for primary procedure]) shattered as a result of trauma.

Next, he places structural bone allografts (20931, Allograft for spine surgery only; structural) to reconstruct the resected vertebrae by arthrodesis (22556, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; thoracic; and 2 x +22585, ... each additional interspace [list separately in addition to code for primary procedure]). Finally, he strengthens the spine using instrumentation (22846, Anterior instrumentation; 4 to 7 vertebral segments).

Should you choose modifier -25, -51 or -59?

Solution #4: You should report the primary procedure (63087) and add-on codes 63088 and 22585 with no modifiers appended. Likewise, CPT designates instrumentation and bone graft codes, including 22846 and 20931, as modifier -51 exempt.

You should, however, append modifier -51 to principal arthrodesis code 22556 to describe its status as a multiple procedure in addition to 63087, Neal says.