Orthopedic Coding Alert

Do you know which approach your surgeon used during the fusion?

The basics: Coders will need to note the reason the surgeon is performing the fusion; further, they’ll need to dig for other details such as technique and approach.

Deni Adams, CPC, CPB, CPPM, CEMC, CPEDC, CCA, director of coding and implementation services at Kaleidoscope Health Systems, is an experienced spinal surgery coder. Here’s what she had to say during her “Intro to Spinal Fusion Coding” at HEALTHCON Regional 2023 in Washington, D.C.

Know These Elements for Optimal Fusion Coding

There are a number of conditions that could be made better with spinal fusion. According to Adams, the most common conditions are:

• Fracture
• Degeneration
• Radiculopathy with instability
• Myelopathy
• Stenosis with instability
• Misalignment

Code also: There are also some special rules on reporting spinal fusion that could benefit the practice. Coders can report instrumentation, grafts, and stereotactic navigation separately with fusion codes (when performed).

Know Each Approach Type

Approach used in spinal fusion is vital toward securing the correct CPT^® code for your surgeon’s services. Once you’ve decided on the approach your surgeon used, Adams said you would need this information on surgery specifics:

• Regions operated on: Cervical, thoracic, lumbar, sacral
• How many interspace(s): C4-C6, T3-T5, etc.
• Type of implant(s) or graft(s)
• Status of instrumentation: New, replaced, or removed?

More on approach: Adams ran down the different types of approaches your surgeon might use during a fusion. Remember to look for this in the encounter notes, as it will make your code choice clearer:

• Prone/Posterior/Posterior Lateral: “The patient is prone [face down] on the operating table, and the incision made into the back or neck,” said Adams.
• Supine/anterior: The patient is face up on the operating table, and the incision is made into the neck or belly.
• Lateral/transverse process/extracavitary: The patient is placed on their side or prone, “and the incision [is] made off to the side or next to the surgical structure,” according to Adams.
• Transpedicular: The patient is prone on the operating table, and the incision is made into the back off to the side of the surgical structure. Pedicle is removed to access anterior structures of spine
• Costovertebral: The patient is prone on the operating table. An incision is made into the back of the chest off to the side of the surgical structure. A small section of rib is removed to expose anterolateral structures of spine. The costovertebral joint and lateral edge of the vertebral endplates are drilled to expose the lateral annulus.

Rely on These Codes to Report Interbody, Anterior/Anterolateral Fusions

Once you’ve got the basics of terminology and technique down for spinal fusion, it’s time to move onto the codes. Since there are too many spinal fusion codes to tackle all of them in a single article, we’ll focus on these types: Anterior interbody, lateral interbody, posterior interbody, and anterior/anterolateral.

Anterior lumbar interbody: If the surgeon performs an anterior lumbar interbody fusion (ALIF), an extreme lateral interbody fusion (XLIF), or oblique lateral interbody fusion (OLIF), or direct lateral interbody fusion (DLIF), you’ll choose 22558 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar).

If your surgeon performs transforaminal lumbar interbody fusion (TLIF), an extraforaminal lumbar interbody fusion (ELIF), a Kambin lumbar interbody fusion (KLIF), or posterior lumbar interbody fusion (PLIF), you’ll choose from the following codes:

• 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))

Lateral extracavitary interbody: If the surgeon performs a thoracic or lumbar lateral extracavitary interbody fusion (LECA), you’ll choose either 22532 (Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic) or 22533 (… lumbar).

Posterior/posterolateral: If the surgeon performs a posterior/ posterolateral spinal fusion, you’ll choose a code from the 22600 (Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment) through +22614 (… each additional interspace (List separately in addition to code for primary procedure)) range.