Orthopedic Coding Alert

Get the lowdown on these add-ons the surgeon might use to aid arthrodesis.

Coders can trip on any number of choices when trying to decide among spinal instrumentation add-on codes: approach, segmental or non-segmental ... or the dreaded interspace miscount.

Follow these steps when deciding on approach and instrumentation type to get the right spinal add-on code each time -- and recoup every bit of reimbursement your surgeon deserves.

Look to Primary Code First

All of the spinal instrumentation codes are add-ons, meaning you must append them to a primary surgical code. For neurosurgery coders, that almost always means arthrodesis in addition to the instrumentation code (e.g., +22840, +22842, +22847).

Bottom line: "By code description, you will not be paid for instrumentation without arthrodesis. Be sure that the correct arthrodesis code is included in the charge," warns Rena Hall, CPC, coder/billing/ insurance coordinator for Kansas City Neurosurgery.

Don't Be Misled by 'Instrumentation' Element of Codes

Location of approach is actually the most important piece of info when deciding on the correct instrumentation code; ironically, the type of instrumentation is secondary information when deciding on an instrumentation code; confirms Peggy Piske, coder at Illinois Neurological Institute.

Reality: "The 'instrumentation' is designed to be attached to the vertebral bones by either anterior or posterior means," explains Hall.

So the real challenge is discovering whether or not the approach is anterior (+22845- +22847) or posterior (+22840, +22842, +22844, +22848). When a coder looks at encounter notes, there are a few ways to tell the approach method.

"The surgeon should specify what approach was used, but there are times when they don't," confirms Deidra Colin, abstract coder in the departments of neurosurgery, anesthesiology and orthopedics for Ochsner Foundation Hospital in New Orleans.

In those cases, you might be able to identify the surgeon's approach with key terms. "Look for keywords such as 'prone' [indicates posterior] or 'supine' [indicates anterior]," Hall recommends.

Other terms and descriptions that might indicate whether the surgeon took an anterior or posterior approach include: a description of thoracotomy or laparotomy (indicates anterior), a description of plate fixation to the vertebral body (indicates anterior), use of lateral mass or pedicle screw fixation (indicates posterior) and laminar hooks or facet screws (indicates posterior).

Count Spaces for Correct Anterior Instrumentation Code

Once you've decided that the orthopaedic surgeon used anterior instrumentation, count up the number of vertebrae spanned and pick the corresponding code.

Example: The spine surgeon performs arthrodesis on a supine patient at interspaces C7-T1 and T1-T2, and then places instrumentation from C7-T2. In this instance, you should report the following:

• 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2) for the initial arthrodesis
• +22585 (... each additional interspace [List separately in addition to code for primary procedure]) for the second interspace
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to code for primary procedure]) for the instrumentation.

Determine Whether Segmental or Not for Posterior Claims

For claims involving posterior instrumentation, you'll still need to count vertebral segments before choosing a code. Before filing the claim, however, you'll also have to decide whether the instrumentation was segmental or non-segmental, Colin says.

The difference: "If the rods or devices are connected only at the top and bottom, this would be non-segmental instrumentation; if there are connections in between the top and bottom, it is segmental," Hall explains.

So if notes indicate that the surgeon provided instrumentation for a prone patient using dual rods and hooks between T8 and T11 with fixation at T8, T9, T10, and T11 you'd report +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]) for the instrumentation.

Check Out This Posterior Encounter

Let the following clinical example guide your posterior instrumentation coding:

Operative notes indicate the spine surgeon provides the following surgical service to a "prone patient with L5/S1 spondylosis":

lumbar arthrodesis with interbody prosthetic device, transpedicular side approach with decompression of the spinal nerve roots and non-segmental instrumentation using pedicle screw fixation.

For this encounter, you would report the following:

• 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disc], single segment; lumbar [including transfacet, or lateral extraforaminal approach] [e.g., far lateral herniated intervertebral disc])
• 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) for the posterior interbody arthrodesis
• modifier 51 (Multiple procedures) appended to 22630 to represent the separate nature of the two procedures +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]]) appended to 63056 for the posterior instrumentation
• +22851(Application of intervertebral biomechanical device[s] [e.g., synthetic cage[s], threaded bone dowel[s], methylmethacrylate) to vertebral defect or interspace [List separately in addition to code for primary procedure]) appended to 22630 to represent the interbody device insertion
• 721.3 (Lumbosacral spondylosis without myelopathy; lumbar or lumbosacral) appended to 22630, 63056,
• +22851 and +22840 to represent the patient's spondylosis.