Orthopedic Coding Alert

Pediatric orthopedists who perform vertebral body stapling on scoliosis (737.x) patients should report the unlisted spine procedure code (22899) not the spine deformity codes (22800-22819) for these surgical services.

During vertebral body stapling, the orthopedic surgeon thorascopically applies staples to the convex side of the curve. This procedure stabilizes the scoliosis and arrests growth on the curved side of the spine. "Currently, no CPT code exists for vertebral stapling, so practices should assign the unlisted-procedure code (22899) for it," says Annette Grady, CPC, CPC-H, director of reimbursement at the Bone and Joint Center in North Dakota and the chairwoman for the North American Spine Society's administrative task force.

Because practices assign the "Spine Deformity" codes to scoliosis-related arthrodesis, some orthopedists erroneously report these codes with modifier -52 (Reduced services) when they perform vertebral stapling. The 22800 series, however, involves resection, or reconstruction, of more than one spinal segment. During arthrodesis, the orthopedist might shave and reshape existing bone to straighten curvature, insert bone grafts, or apply instrumentation to straighten a crooked or curved spine.

"When we bill arthrodesis for scoliosis patients, we have to send the operative report with the claim or our Medicare carrier will automatically deny the service," says James Brackin, coder at Randall Brackin Billing, a medical reimbursement consulting business. "We attach the operative report to the CMS 1500 form and submit a paper claim instead of an electronic one."

Because orthopedists must occasionally use both anterior and posterior arthrodesis approaches for scoliosis patients, they tend to fall victim to another common coding error. "I've seen practices submit claims using 22804 (Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments) to represent both anterior and posterior approaches of seven vertebral segments," Brackin says. "This code should only be used for posterior approach, so it's incorrect coding to imply you addressed 14 posterior segments when you really only addressed seven segments on each side."

Instead, report one unit of 22802 (Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments) and one unit of 22810 (Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments).

Suppose the patient returns to your practice annually postarthrodesis to confirm that her spine is healthy. You can't report the scoliosis diagnosis because the patient's spine no longer curves. "For follow-up after the patient had arthrodesis, I would report V45.4 (Other postsurgical states, arthrodesis status) with V13.5 (Personal history of other musculoskeletal disorders)," Grady says.

Note: Some insurers may prefer V67.09 (Follow-up examination following other surgery) instead of or in addition to the above codes.

HCPCS includes nearly 30 orthotics codes for scoliosis procedures, mainly because growing pediatric patients require constant brace revisions and modifications to accommodate their growing spines. "The HCPCS Level III codes L1000-L1499 describe these services," Grady says.

Suppose you fit a patient for a thoracic-lumbosacral orthosis (TLSO) in July. She returns to the practice in November and measures a half-inch taller than before, requiring that an anterior thoracic brace extension be added to her prior orthosis.

The practice should report L1200 (TLSO, inclusive of furnishing initial orthosis only) in July and L1220 for the return visit (Addition to TLSO, [low profile], anterior thoracic extension) in November.