Orthopedic Coding Alert

Tip: Distinguish removal and reinsertion.

To ensure reimbursement for spinal instrumentation, you will need to confirm if your surgeon is removing or replacing the instrumentation and check if modifiers apply. Learn more with some examples that can guide your coding.

1. Report Removal and Reinsertion

You may report instrumentation removal in the event of damage, rejection, or removal done to adjust the instrumentation.

Exception: Remember that you do not report removal of instrumentation when your surgeon does the removal to explore the spinal fusion. “Since it is necessary to remove spinal instrumentation in order to examine a fusion bed for successful arthrodesis including observation for movement, instrumentation removal is considered a bundled service,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. “In an exception, remember that you do not report removal of instrumentation when your surgeon reinserts instrumentation, even if a new set of implants is placed.”

You select from the following codes when reporting the instrumentation removal:

• 22850 — Removal of posterior non-segmental instrumentation (e.g., Harrington rod)
• 22852 — Removal of posterior segmental instrumentation
• 22855 — Removal of anterior instrumentation.

You report reinsertion with 22849 (Reinsertion of spinal fixation device) when your surgeon removes and the reinserts the instrumentation, such as when there is an implant failure or loosening.

Hint: “The anterior removal of instrumentation code 22855, the reinsertion of instrumentation code 22849, and the posterior removal of instrumentation codes 22850 and 22852 are stand-alone codes that have 90-day global periods and are subject to the 51 modifier,” says Przybylski.

Note: You also report for bone graft (20930-20938) with spinal fusion. 

2. Manage the Modifiers

According to CPT^®, spinal instrumentation procedures are essentially bilateral. Therefore, you should never append modifier 50 (Bilateral procedures) to the anterior or posterior instrumentation codes.  

You should also never append modifier 51 (Multiple procedures) to the instrumentation codes with the exception of the 90 day global codes listed above.

When modifiers would apply: Spinal instrumentation is an additional yet independent procedure and you always look for the primary procedure. “There may be circumstances in which the 59 modifier is applied to instrumentation codes,” says Przybylski. “For example, if interbody prosthetic devices are placed at separate defects, 22851 would be reported twice, the second with the 59 modifier.” You can however make a logical use of modifiers 78 (Return to the operating room for a related procedure during the postoperative period) or 79 (Unrelated procedure or service by the same physician during the postoperative period) if applicable.

If you read that your surgeon performed an unrelated procedure during the global period of a previous fusion/instrumentation, you append modifier 79 to the appropriate procedure code(s). “One would expect a separate diagnostic code(s) for the underlying medical condition(s) if the procedure is truly unrelated,” says Przybylski.

Example 1: If your surgeon performed an anterior cervical fusion during the global period of a lumbar fusion/instrumentation, you report code 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace ([other than for decompression]; cervical below C2) with modifier 79.

For a related procedure during the global period, you append modifier 78.

Example 2: When your surgeon returns the patient to the OR during the global period for removal of a previously placed instrumentation after the device failed, you append modifier 78. Thus, you report 22850-78 for the removal of posterior non-segmental instrumentation done in the global period. “In this example, the subsequent procedure is clearly related to the original procedure. Even if you use a new diagnostic code for implant failure, the 78 modifier would still apply,” says Przybylski.