Orthopedic Coding Alert

Dispel These 3 Common Spine Coding Myths At the Root of Reduced Reimbursement

Published on Fri Jul 01, 2005

Surprise: You can report instrumentation removal during repeat fusions

A surgeon performs both posterior and anterior arthrodesis, but the insurer denies 22554 and bundles it into 22600 - and you write off about $675 that Medicare allots for 22554 under the multiple-procedure rule, right? Not so fast. You've just fallen prey to one of the top-three spine coding myths.

The following spine coding scenarios will help you tighten up your claims and give your appeals some muscle.

Myth #1: You can't bill instrumentation removal during repeat fusions

Suppose your surgeon places segmental instrumentation during a spinal fusion, but a year later the patient returns complaining of severe low back pain, and the surgeon suspects pseudarthrosis.

The surgeon returns the patient to the operating room (OR), removes the instrumentation and explores the fusion mass (22830, Exploration of spinal fusion). The orthopedic surgeon confirms pseudarthrosis and performs a redo fusion.

"Some Medicare carriers say you can't use the instrumentation removal codes with 22830," said Greg Przybylski, MD, professor and director of neurosurgery at the NJ Neuroscience Institute at JFK Medical Center and Seton Hall University, at a May Coding Institute audioconference titled "Eight Stellar Strategies for Spine Surgery Pay-up."

Those Medicare payers are wrong, Przybylski says. "CPT added language in 2005 that states the AMA's position, which is that you can use the instrumentation removal/reinsertion codes with 22830."

The applicable removal/reinsertion codes you should report are:

22849 - Reinsertion of spinal fixation device

22850 - Removal of posterior nonsegmental instrumentation (e.g., Harrington rod)

22852 - Removal of posterior segmental instrumentation

22855 - Removal of anterior instrumentation.

Justification: CPT states, "Report modifier 51 (Multiple procedures) with 22849, 22850, 22852 and 22855 when instrumentation reinsertion or removal is reported with other definitive procedures such as arthrodesis, decompression, and exploration of fusion."

If your insurer continues to deny your instrumentation removal claims when you report spinal fusion, copy the applicable page of CPT (the notation is printed directly above code 22830's descriptor) and send it with your appeal, along with a short letter from the surgeon.

Myth #2: You can bill corpectomy with lumbar interbody fusion

Your spine surgeon turns in the following operative note:

"I performed a transforaminal lumbar interbody fusion at L4-5, and performed osteotomy anteriorly in the disk space to augment the fusion and posteriorly to facilitate placement of the cages.

"I prepared the end plates and packed autograft bone anteriorly and laterally, then packed 9- x 22-mm cages with cancellous autograft as placed."

Your surgeon recommends that you report the arthrodesis code along with a partial corpectomy (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 your office manager agrees. They have just been sucked into myth number two.

Reality: You should not report the corpectomy, says Matthew Twetten, manager of health policy and reimbursement at the North American Spine Society (NASS).

Right way: You should report the following codes, Twetten says:

22630 - Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace (other than for decompression), single interspace; lumbar

22851 - Application of intervertebral biomechanical device(s) (e.g., synthetic cage[s], threaded bone dowel[s], methylmethacrylate) to vertebral defect or interspace

20936, 20937 or 20938 (Autograft for spine surgery only...) for the bone grafting, depending on the location.

"In this scenario, the spine surgeon is incorrect in billing a partial corpectomy, and to do so is to engage in misleading overbilling, something NASS adamantly advises all practitioners from engaging in," Twetten says.

Myth #3: Carriers are probably correct in bundling anterior surgeries with posterior procedures

If your spine surgeon performs both posterior and anterior surgeries on a patient on the same date, you should not have to write off payment for one of the procedures that he performs.

For example, if your surgeon performs anterior interbody arthrodesis (22554) and posterior arthrodesis (22600), your insurer should not bundle 22554 into 22600. But many carriers do just that, and some orthopedic practices simply accept the denial.

Surgeons perform anterior and posterior surgeries through separate exposures, and the work is completely separate, Przybylski says.

Strategy: Practices that face such denials should arrange for the surgeon to meet with the payer representative, Przybylski says.

The surgeon should explain that the surgeries are separate from one another. In addition, the surgeon should describe how an arthrodesis on one side of the spine has nothing to do with the other side.