Orthopedic Coding Alert

When your orthopedist indicates PLIF, TLIF, or similar procedures in his operative notes you know he completed spinal fusion, but might not understand much more unless you focus on the approach.

Heads up: "When coding for any of these procedures, the coder needs to be most aware of the area of approach," says Judy Larson, CPC, with Rockford Orthopedic in Rockford, Ill. Learn the differences between four of the most common types and how to report them to keep from tripping up your claims.

PLIF is an acronym for posterior lumbar interbody fusion. Your surgeon reaches the vertebrae through an incision in the patient's back. He removes the affected disc and surrounding tissue, then prepares the bone surfaces of adjacent vertebrae for fusion. He completes the procedure by inserting a bone graft, structural autograft or allograft, or biomechanical spacer implant to promote fusion between the vertebrae. He'll also insert instrumentation to further stabilize the spine.

Code it: Because of the surgeon's posterior approach, report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) and +22632 (... each additional interspace [List separately in addition to code for primary procedure]) as appropriate. Once you verify the type of  instrumentation and number of segments, code from:

• +22840 -- Posterior non-segmental instrumentation (e.g., 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)

• +22841 -- Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)

• +22842 -- Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)

• +22843 -- ... 7 to 12 vertebral segments (List separately in addition to code for primary procedure)

• +22844 -- ... 13 or more vertebral segments (List separately in addition to code for primary procedure).

Transforaminal lumbar interbody fusion, or TLIF, is a refinement of the PLIF procedure.

"The TLIF technique involves approaching the spine in a similar manner as the PLIF approach, but more from the side of the spinal canal through a midline incision in the patient's back," Larson explains.

TLIF reduces the amount of muscle dissection and minimizes the manipulation necessary for the surgeon to reach the vertebrae, discs, and nerves. TLIF allows the surgeon to use endoscopic techniques for spinal fusion that generally are less traumatic to the spine.

Code it: As with PLIF, you'll report 22630 for TLIF and add +22632 when needed. Your instrumentation choices also remain the same because you're still coding for a posterior approach.

If the operative note specifies ALIF, your surgeon completed anterior lumbar interbody fusion. The procedure is similar to PLIF and TLIF, but the surgeon uses an anterior approach, usually through an incision in the lower abdominal area or the patient's side. Whether the surgeon chooses an anterior or posterior approach usually is at his discretion and based on his or her preference, says Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.

Code it: Because of the anterior approach, you submit 22558 (Arthrodesis, anterior body technique, including minimal discectomy to prepare interspace [other than for decompression]; lumbar). Include +22585 (... each additional interspace [List separately in addition to code for primary procedure]) for multiple levels.

The change in approach also affects your instrumentation coding. Now you'll turn to codes:

• +22845 -- Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)

• +22846 -- ... 4 to 7 vertebral segments (List separately in addition to code for primary procedure)

• +22847 -- ... 8 or more vertebral segments (List separately in addition to code for primary procedure).

One of the newest spinal fusion techniques is extreme lateral interbody fusion, or XLIF. "The surgeon accesses the disc from a small incision on the patient's side," Larson says. "He sometimes makes another small incision just behind the first."

Because the XLIF approach is minimally invasive, the surgeon uses fluoroscopy to provide real-time images of the spine. He removes the disc material and replaces it with a bone graft and cage.

Code it: Report XLIF with 22558 and +22585. Pay attention to your physician's documentation and the additional levels you code, because the surgeon usually can access only one or two levels at a time.