Part B Insider (Multispecialty) Coding Alert

Question: During an operative session, my neurosurgeon performed the following procedures: L4-L5 diskectomy, L5-S1 diskectomy, L4-L5 transforaminal interbody fusion using posterior interbody technique, L5-S1 transforaminal interbody fusion using posterior interbody technique, bone graft placement (autograft), L4-L5 interbody cage placement, L5-S1 cage placement, and L4, L5, S1 bilateral pedicle screw instrumentation. How should I report this procedure?

Alaska Subscriber

Answer: From the description you provide, your surgeon likely performed a transforaminal lumbar interbody fusion (TLIF)procedure. If the surgeon performed the L4- L5 transforaminal interbody fusion using a posterior interbody technique, you should report 22630 (Arthrodesis,posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar).

For the L5-S1 interbody fusion, you should report +22632 (... each additional interspace [List separately in addition to code for primary procedure]). Then, report the appropriate autograft code (20936-20938) for the autograft.

Next, bill one unit of +22851 (Application of intervertebral biomechanical device[s] [e.g.,synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace [List separately in addition to code for primary procedure]) to represent the surgeon's work inserting the interbody cage at L4-L5.

Then, report another unit of +22851 for the L5-S1 cage placement. Append modifier 59 (Distinct procedural service) to show the payer that your neurosurgeon addressed separate levels.

Also, you should report +22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure]) for the screw instrumentation. Because the code's descriptor refers to "3 to 6 vertebral segments," you can report only one unit of this code, despite the fact hat the surgeon inserted screws at three levels.

Don't miss: Because your neurosurgeon only documented a simple diskectomy (meaning as preparation for the fusion, not for the decompression), you wouldn't report codes 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, including open or endoscopically assisted approach; 1 interspace, lumbar) and +63035 (... each additional interspace, cervical or lumbar [List separately in addition to code for primary procedure])