Orthopedic Coding Alert

Question: Encounter notes indicate that on Monday, the surgeon provided a level-four evaluation and management (E/M) service for a new patient with diagnosis of cervicothoracic postural kyphosis. On Tuesday, the surgeon performed anterior arthrodesis for spinal deformity. The notes do not indicate whether casting was used. How can I choose the correct CPT^® code if I don’t know this information?

Texas Subscriber

Answer: You don’t need to know whether casting was used, as the CPT^® codes for this procedure all read “with or without cast.” You will, however, need to know how many vertebral segments your surgeon treated.

Do this: Go back and check the encounter notes for evidence of a vertebral segment count. Then, report:

• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) for the E/M
• Modifier 57 (Decision for surgery) appended to 99204 to show that a significant, separately identifiable E/M occurred before the arthrodesis
• M40.03 (Postural kyphosis, cervicothoracic region) appended to 99204 to indicate the patient’s condition One of the following codes for the arthrodesis:
• 22808 (Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments)
• 22810 (… 4 to 7 vertebral segments)
• 22812 (… 8 or more vertebral segments)
• M40.03 appended to the arthrodesis code to indicate the patient’s condition.