Orthopedic Coding Alert

Question: A 14-year-old patient presents with well-compensated double curve pattern adolescent idiopathic thoracic scoliosis. The patient was advised to undergo surgery due to the long-term negative impact of signs and symptoms of scoliosis upon her health. The surgeon performs posterior spinal fusion to correct the scoliosis from T2-L4 using morselized allograft bone. They used posterior instrumentation from T2-L4 as well. How should I code this encounter?

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Answer: For this patient, you should report:

• 22804 (Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments) for the spinal fusion
• +22844 (Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)) for the posterior instrumentation
• +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)) for the allograft
• M41.124 (Adolescent idiopathic scoliosis, thoracic region) appended to 22804, +22844, and +20930 to represent the patient’s scoliosis.