Orthopedic Coding Alert

Nail down location and instrumentation type to keep your coding on the straight and narrow

If your surgeon uses spinal instrumentation, you don't have to get used to diminished reimbursement. Once you know which services are included in the surgery and what type of instrumentation your surgeon used, you-ll know when you can collect and when the service is bundled.

When your surgeon inserts spinal instrumentation, you should first determine which type of device he used. CPT includes 10 codes for inserting spinal instrumentation:

- 22840 -- Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation)

- 22841 -- Internal spinal fixation by wiring of spinous processes

- 22842 -- Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminal wires); 3 to 6 vertebral segments

- 22843 -- Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminal wires); 7 to 12 vertebral segments

- 22844 -- Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminal wires); 13 or more vertebral segments

- 22845 -- Anterior instrumentation; 2 to 3 vertebral segments

- 22846 -- Anterior instrumentation; 4 to 7 vertebral segments

- 22847 -- Anterior instrumentation; 8 or more vertebral segments

- 22848 -- Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum

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

Keep in mind: CPT codes differentiate between posterior instrumentation (22840, 22842-22844) and anterior instrumentation (22845-22847).

Guidance: Generally, the instrumentation type corresponds to the surgical approach (anterior or posterior). If the surgeon places posterior instrumentation, you must further determine if the device is segmental (22842-22844) or nonsegmental (22840).

The surest way to do this is to count the number of fixation points. -If instrumentation attaches to only two vertebral segments, regardless of the span, the instrumentation is considered non-segmental,- says Gregory Przybyl-ski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, N.J. -If the instrumentation attaches to three or more vertebral segments, the instrumentation is considered segmental.-

In some cases, the surgeon places a metal cage or other prosthetic device for stabilization in an area where he removed a large portion of the vertebra. This represents a third type of instrumentation, which you should report using 22851. Report only a single unit of 22851, regardless of how many devices the surgeon places at one level. But if the surgeon places devices on multiple spinal levels, you may report multiple units of 22851 (one unit for each individual spinal level).

Example 1: The surgeon places two cages at level T6-T7.

Solution 1: Report one unit of 22851.

Example 2: The surgeon places two cages at level T5-T6 and two cages at level T6-7.

Solution 2: Report 22851 x 2. Some payers may require you to append modifier 59 (Distinct procedural service) to the -additional- unit to demonstrate that the physician performed it at a separate anatomic location(s).

Avoid Modifier 51 for Instrumentation

According to CPT, most spinal instrumentation codes (22840-22848 and 22851) are modifier 51 (Multiple procedures) exempt.

For example: The surgeon performs arthrodesis at interspaces C6-7, C7-T1 and T1-2. He then places anterior instrumentation attached at C6 and T2.

In this case, report 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2), 22556-51 (... thoracic) and +22585 (... each additional interspace [list separately in addition to code for primary procedure]) for the arthrodesis and 22846 (Anterior instrumentation; 4 to 7 vertebral segments) for the instrumentation.

Be Careful With Instrumentation Removal Codes

If the surgeon removes instrumentation to necessitate an exploration of fusion, you cannot charge for the instrumentation removal, Przybylski says.

On rare occasions, however, the surgeon may have to remove spinal instrumentation because the instrumentation breaks, the patient's body rejects it, or the patient requires an adjustment in the instrumentation type. In these cases, you can separately code the instrumentation removal.

Here's how: If the orthopedic surgeon returns the patient to the operating room during the global surgical period because of ongoing infection at the instrumentation site, you should append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the appropriate spinal instrumentation removal code:

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

 - 22852 -- Removal of posterior segmental instrumentation

 - 22855 -- Removal of anterior instrumentation.

Instrumentation reinsertion: If the surgeon reinserts instrumentation following the procedure (such as a repeat fusion), you should report 22849 (Reinsertion of spinal fixation device).