Orthopedic Coding Alert

Providers rely on injections, rehab, PT before surgery.

Once your provider confirms a case of spinal stenosis and diagnoses it, they’ll be ready to treat the condition. Surgery for spinal stenosis is always a possibility, but there are also less invasive methods your provider might attempt before opting for surgery.

“Treatment for diagnosis of spinal stenosis can include such modalities as medication, physical therapy [PT], steroid injections and surgery,” explains Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, AAPC ICD-10-CM Proficient, AAPC Fellow, senior manager of healthcare consulting at Seim Johnson, LLP in Omaha, Nebraska.

Read on for more information on the most used spinal stenosis treatments, and how to code for them.

Use This Guide for PT, Steroids

The codes for PT and steroid injections you’d report for spinal stenosis treatment include, but are not limited to:

• Physical therapy 97161 (Physical therapy evaluation: low complexity, requiring these components: …) through 97163 (Physical therapy evaluation: high complexity, requiring these components: …)
• Rehab: 97010 (Application of a modality to 1 or more areas; hot or cold packs) through 97028 (Application of a modality to 1 or more areas; ultraviolet)
• Steroid injections: 62320 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance) through 62327 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT))

Example: Encounter notes indicate that a patient suffers from cervicothoracic spinal stenosis. The provider performs a steroid injection into the cervicothoracic area with guidance. For this encounter, you’d report 62324 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance) for the injection with M48.03 (Spinal stenosis, cervicothoracic region) appended to represent the patient’s spinal stenosis.

Surgical Stenosis Tx = Lots of CPT^® Codes

There are many surgical treatment options for patients with spinal stenosis, which means there are a lot of CPT^® codes for these treatments. Deciding the proper CPT^® code for each treatment will involve some work for the coder to determine anatomy, technique, approach, and type of surgery — among other factors.

“Surgery could be a variety of codes including such procedures as percutaneous image-guided lumbar decompression, lumbar laminectomy, cervical laminectomy, laminotomy, laminoplasty and others,” says Swanson.

The codes associated with these spinal stenosis treatments include, but are not limited to, the following:

• 22610 (Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, when performed))
• 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar) through +22634 (… each additional interspace (List separately in addition to code for primary procedure))
• +22840 (Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)) through +22859 (Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure))
• 22862 (Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar) through 22865 (Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar)
• 62380 (Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar)
• 63045 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical) through +63048 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure))
• 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)) and +63057 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure))
• 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 (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; each additional segment (List separately in addition to code for primary procedure))
• 63090 (Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment) and +63091 (Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure))

Postscript: Check Payer Policy on Conservative Tx

If you are coding a surgical procedure for a spinal stenosis patient, you might need to include proof of more conservative, less invasive procedures your provider employed to treat the patient prior to opting for surgery. This can be included in the patient record, and will likely consist of the conservative treatments listed above: steroid injections, PT, and rehab.

“Many insurance carriers have policies that require a time frame of conservative treatment prior to surgery,” says Lynn M. Anderanin, CPC,CPB,CPMA,CPPM, CPC-I,COSC, senior coding educator at Healthcare Information Services, LLC in Park Ridge, Illinois.

“By statute, Medicare may only pay for items and services that are ‘reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,’ unless there is another statutory authorization for payment,” explains Swanson. “Documentation should routinely support treatment modalities the patient has tried, response to treatment and the medical indications for surgery.”