Wiki RE: Instrumentation Removal

[shofner14]

RE: Instrumentation Removal

I am coding a surgery for posterior fusion where our neurosurgeon is working on L3-L4 and L4-L5 interspaces. He is removing existing hardware that was previously placed by another surgeon at L4-L5
and placing new hardware at L3-L4 and replacing the previous hardware at L4-L5. Can our provider bill for hardware placement/removal at L4-L5 in addition to L3-L4?

 

[mhstrauss]

I am coding a surgery for posterior fusion where our neurosurgeon is working on L3-L4 and L4-L5 interspaces. He is removing existing hardware that was previously placed by another surgeon at L4-L5
and placing new hardware at L3-L4 and replacing the previous hardware at L4-L5. Can our provider bill for hardware placement/removal at L4-L5 in addition to L3-L4?

No. 22852 is included in 22842, per CCI Edits. There's also a paragraph at the beginning of the Instrumentation section of the CPT book explaining that it's not appropriate to code removal along with new instrumentation in this situation.

HTH!