Orthopedic Coding Alert

Include evidence of presurgical treatment attempts on the claim.

In September, we focused on the very detailed basics of spinal fusion coding: Different surgical approaches and how to choose a code for spinal fusions using anterior interbody, lateral interbody, posterior interbody, and anterior/anterolateral techniques.

As this is a rich coding area, we’re back with more spinal fusion coding advice. This month, we’ll take a look at how your surgeon would reach the decision to perform a spinal fusion. Then, we’ll look at coding conventions for the remaining techniques: lateral extracavitary and posterior/ posterolateral/lateral transverse.

This advice was proffered by Deni Adams, CPC, CPB, CPPM, CEMC, CPEDC, CCA, director of coding and implementation services at Kaleidoscope Health Systems in Minneapolis, during her presentation “Intro to Spinal Fusion Coding” at HEALTHCON Regional 2023 in Washington, D.C. Here’s what she had to say.

Several Services Will Predate Spinal Fusions

A surgeon decides that a patient needs a spinal fusion based on several factors. Here’s how they make that determination:

Evaluation and management (E/M): The physician will always start the road to spinal fusion surgery with an E/M service. During this encounter, the surgeon will evaluate the patient’s symptoms, such as chronic back or neck pain, weakness, numbness, or tingling in the extremities, and difficulty walking or performing daily activities. They will also conduct a thorough physical examination to evaluate the patient’s range of motion, muscle strength, reflexes, and any signs of spinal instability or deformity.

These visits are typically office/outpatient E/Ms, meaning you’d report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) depending on encounter specifics. Note the locale/patient status during the E/M however, as the E/M could also occur in a hospital/inpatient setting.

If the case is especially complex, the surgeon might also consult with other specialists — such as neurologists, pain management physicians, or physical therapists — to ensure a comprehensive evaluation.

Diagnostic imaging: If the surgeon suspects a pressing spinal issue, they will use imaging tests to assess the structural abnormalities of the spine. These tests could be X-rays, magnetic resonance imaging (MRI), or computed tomography (CT) scans. The images from these tests will provide detailed information about herniated discs, spinal stenosis, spondylolisthesis, or other conditions that may require fusion.

Failed conservative treatments: Surgeons will typically consider a spinal fusion after nonsurgical treatments have been exhausted or proven ineffective. These more conservative treatments could include physical therapy (PT), pain medications, spinal injections, or other conservative measures. If these treatments fail to alleviate the patient’s symptoms, the surgeon might suggest a spinal fusion.

Rely on These Codes for Lateral Extracavitary Approach

Once spinal fusion surgery is decided, coders will need to move to a different section of the CPT® book to choose their codes. When it is indicated that the surgeon used a lateral extracavitary technique, Adams pointed to the following codes:

• 22532 (Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic)
• 22533 (… lumbar)
• +22534 (… thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure))

During this surgery performed through a posterior surgical incision, paraspinous muscles are exposed and lifted off the spinous processes, then divided and lifted off the ribs. In the thoracic region, the corresponding rib is dissected from the intercostal muscles and resected in one piece from the curve to the costovertebral connection. The surgeon removes the transverse process, facet, and pedicle anterior to the paraspinous muscles to gain access to the dura and vertebral body.

Remember that each of these codes is for a single interspace, Adams said.

Rely on These Codes for Posterior/Posterolateral Technique

If, however, notes indicate that the surgeon performed a spinal fusion using posterior/posterolateral technique, Adams said to note the following codes:

• 22590 (Arthrodesis, posterior technique, craniocervical (occiput-C2))
• 22595 (Arthrodesis, posterior technique, atlas-axis (C1-C2))
• 22600 (Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment)
• 22610 (… thoracic (with lateral transverse technique, when performed))
• 22612 (… lumbar (with lateral transverse technique, when performed))
• +22614 (… each additional interspace (List separately in addition to code for primary procedure))
• 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar)
• +22632 (… each additional interspace (List separately in addition to code for primary procedure))
• 22633 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar)
• +22634 (… each additional interspace (List separately in addition to code for primary procedure))

Adams had advice for coders reporting these codes for posterior/posterolateral approach spinal fusions:

• Each code is for a single interspace for 22600-+22614; 22590-22595 have combined levels
• Use +22614 with 22600-22612, 22630, or 22633
• You cannot report 22590 with 22595, but can you can report either of these codes with 22600
• Use +22632 with 22612, 22630, or 22633
• Use +22634 with 22633 only
• Remember to bill the instrumentation and/or grafts separately (+22840-+22859 and +20930-+20938)
• You can report laminectomy for decompression in addition to codes for arthrodesis.