Orthopedic Coding Alert

Question: Our surgeon performed a 3-level anterior cervical fusion w/corpectomy, discectomy and decompression as well as hardware removal, C5 to T1. He used PEEK interspacers w/morsellized bone graft, as well as bone extender and Atlantis plate with screws. He completed a 5-level posterior cervical fusion w/C3-C5 laminectomy, lateral mass fusion and lateral mass plating from C3 to T1 with guidance for help in placing the screws. How should I code this encounter?

Pennsylvania Subscriber

Answer: There is insufficient information to provide specific coding recommendations. Performance of a corpectomy requires removal of more than half of the vertebral body and includes the adjacent level discectomies. The use of PEEK interspacers implies placement of interspace prosthetic devices which are used after anterior cervical discectomy rather than after corpectomy.

If interspace decompressions were performed at three locations (C56, C67, C7T1), you would report 22551, 22552 times 2, 22851, 22851-59, 22851-59, 22845, 20936, and 20930 for the anterior procedure.

For the posterior portion of the surgery, the laminectomy performed does not include description of facetectomy and/or foraminotomy. The posterior instrumentation needs to specify the number of segments that have fixation to differentiate non-segmental from segmental instrumentation.

Assuming at least one additional point of fixation between C5 and T1, the posterior portion would be reported with 63015-51, 22600-51, 22614 x 4, and 22846.

Bone graft codes may also be applicable if performed. The type of "guidance" was not specified. Although radiographic or fluoroscopic guidance is a bundled service, use of computer-assisted stereotactic navigation would be reported with 61783.