Orthopedic Coding Alert

If it’s below C2, arthrodesis coding gets complicated.

In an orthopedic practice, patients will at times require cervical arthrodesis below C2. There are dozens of cervical disorders — from displaced discs to spondylosis — that might be treated with arthrodesis.

Also, there are additional coding opportunities on some of these claims if you know where to look. There are several services represented with add-on codes that you might need to add to your claim in order to max out your practice’s rightful reimbursement.

Don’t get confused. Check out this primer on coding cervical arthrodesis below C2.

Check for Presurgical E/M, Imaging

In addition to an office/outpatient evaluation and management (E/M) service to address a patient’s cervical issues, the surgeon will likely order some type of imaging test (or tests) to confirm that the patient needs cervical arthrodesis.

“The process would normally start off with an office visit where X-rays are performed. If the patient has a recent MRI with them, the results are usually reviewed and discussed with the patient. If not, the physician will order an MRI as well,” explains Wayne Conway, CPC, CRC, CGSC, COSC, physician coder II at WakeMed Physicians Practice in Raleigh, North Carolina.

Conway goes on to say that many patients’ chief complaint at the initial visit will be ongoing neck, shoulder, and hand pain. Many times, these patients will suffer recurrent numbness, described as pins-and-needles, in their hands and pain radiating into their shoulders. Often the pain will be described as aching, shooting, or stabbing — and it may even radiate into the lower legs and feet, Conway confirms.

In addition to the X-ray and MRI, a provider might also want to perform a computed tomography (CT). When the surgeon performs cervical imaging (X-ray, MRI, or CT) for potential arthrodesis candidates, you’ll likely see one or two of these codes:

• 72020 (Radiologic examination, spine, single view, specify level)
• 72040 (Radiologic examination, spine, cervical; 2 or 3 views)
• 72050 (… 4 or 5 views)
• 72052 (… 6 or more views)
• 72081 (Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view)
• 72082 (… 2 or 3 views)
• 72083 (… 4 or 5 views)
• 72084 (… minimum of 6 views)
• 72125 (Computed tomography, cervical spine; without contrast material)
• 72126 (… with contrast material)
• 72127 (… without contrast material, followed by contrast material(s) and further sections)
• 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material)
• 72142 (… with contrast material(s))
• 72156 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical)

Example: A new patient reports to the surgeon with pain in their neck and upper back radiating to the right arm. After an office E/M that includes moderate-level medical decision making (MDM), the surgeon orders a three-view cervical spine X-ray, as well as an MRI without contrast material. The surgeon then diagnoses the patient with cervical spondylosis at C6-C7.

For this encounter, you’d report:

• 72141 for the MRI
• 72082 for the X-ray
• 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
• M47.22 (Other spondylosis with radiculopathy, cervical region) appended to 72141, 72082, and 99204 to represent the patient’s osteophyte compressing the C7 nerve

Caveat: The above example isn’t necessarily the last step before the surgeon decides on arthrodesis. There will be attempts to treat the condition before opting for surgery. In fact, you payer is likely to insist on more conservative means of treatment before the surgeon opts for surgery.

“Before surgery is scheduled patients will often go through extensive nonoperative treatments including various medications, physical therapy, and steroid injections to see if this will help remedy the problem. Most carriers will want to exhaust all nonoperative treatments before surgery is scheduled,” adds Conway.

Code With This Combo for Arthrodesis

When the surgeon decides to perform a single-interspace arthrodesis, you’ll report it with 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2).

Remember to report a code for each interspace the surgeon treats with arthrodesis; if multiple levels are treated, report each additional level beyond the first with +22552 (… cervical below C2, each additional interspace (List separately in addition to code for primary procedure)). Also, remember to look for other codeable procedures — likely in the form of add-on codes — that you might report with the arthrodesis.

“In all levels, report additional add-ons for grafts and instrumentation if used,” explains Jessica Miller, MHA, CPC, VP revenue cycle for Ortmann Healthcare Consulting Services.

Conway concurs, saying “sometimes an intervertebral biomechanical device or spinal cage is also used when performing an anterior cervical fusion in conjunction with an interbody arthrodesis. Also, anterior instrumentation that is separate and not an integral component to the biomechanical device is separately reportable.”

Examples of add-ons you might include with 22551/+22552 include:

• +22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure))
• +20930 (Allograft, morselized, or placement of osteopro­motive material, for spine surgery only (List separately in addition to code for primary procedure))
• +20931 (Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure))
• +20936 (Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure))
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)).
• +22846 (… 4 to 7 vertebral segments (List separately in addition to code for primary procedure)).