Medical coding guidelines for Spine procedure
Coding guidelines for arthrodesis procedure
Medical coding guidelines for Spine procedure
Definitive Procedure
• Excision
• Osteotomy
• Fracture and/or Dislocation
• Vertebroplasty and vertebral Augmentation
• Arthrodesis
• Spinal deformity
Disc / Segment
Vertebral interspace – Non-bony compartment between two adjacent vertebral bodies (contain the disc)
Vertebral segment– Single complete vertebral bone
Coding Guidelines Spine procedure
· Exploration (22830 ) of a surgical field shall not be report with main procedure (Definite procedure) if it is in the same anatomic area. If different anatomic area may be reported separately with modifier 59 or XS.
· Intraoperative neurophysiology testing (HCPCS/CPT codes 95940, 95941, and G0453) shall not be reported by the physician performing an operative procedure since it is included in the global package. When performed by a different physician during the procedure, it is separately reportable by the second provider/supplier.
· The physician performing an operative procedure shall not bill other 9XXXX neurophysiology testing codes for intraoperative neurophysiology testing (e.g., CPT codes 92585, 95822, 95860, 95861, 95867, 95868, 95870, 95907-95913, 95925-95937) since they are also included in the global package. (CPT code 92585 was deleted January 1, 2021.)
· Spinal arthrodesis, exploration, and instrumentation procedures (CPT codes 22532-22865) and other spinal procedures include manipulation of the spine as an integral component of the procedures. CPT code 22505 (Manipulation of spine requiring anesthesia, any region) shall not be reported separately
· Many spinal procedures are grouped into families of codes where there are separate primary procedure codes describing the procedure at a single vertebral level in the cervical, thoracic, or lumbar region of the spine. Within some families of codes, there is an Add- on Code (AOC) for reporting the same procedure at each additional level without specification of the spinal region for the AOC. When multiple procedures from one of these families of codes are performed at contiguous vertebral levels, a provider/supplier shall report only one primary code within the family of codes for one level and shall report additional contiguous levels using the AOC(s) in the family of codes. The reported primary code should be the one corresponding to the spinal region of the first procedure. If multiple procedures from one of these families of codes are performed through separate skin incisions at multiple vertebral levels that are not contiguous and in different regions of the spine, the provider/supplier may report one primary code for each non-contiguous region.
· For example, the family of CPT codes 22532-22534 describes arthrodesis by lateral extra cavitary technique. CPT code 22532 describes the procedure for a single thoracic vertebral segment. CPT code 22533 describes the procedure for a single lumbar vertebral segment. CPT code 22534 is an AOC describing the procedure for each additional thoracic or lumbar vertebral segment. If a physician performs arthrodesis by lateral extra cavitary technique on contiguous vertebral segments such as T12 and L1, only one primary procedure code (i.e., the one for the first procedure) may be reported. The procedure on the second vertebral body may be reported with CPT code 22534. If a physician performs the procedure at T10 and L4 through separate skin incisions, the provider/supplier may report CPT codes 22532 and 22533.
· If the interspaces span 2 different spinal regions through the same skin incision, the provider/supplier shall report a primary code for the first interspace and an AOC for each additional interspace
· If the interspaces span 2 different spinal regions through different skin incisions, the provider/supplier may report a primary code for the first interspace through each skin incision and an AOC for each additional interspace through the same skin incision.
· If a physician performs arthrodesis across multiple contiguous interspaces through the same skin incision using different techniques, the provider/supplier shall report one primary code for the first interspace and AOC for each additional interspace
· If a physician performs arthrodesis across multiple non-contiguous interspaces through the same skin incision using different techniques, the provider/supplier shall report one primary code for the first interspace and AOCs for each additional interspace.
· If a physician performs arthrodesis across multiple non-contiguous interspaces through different skin incisions using different techniques, the provider/supplier may report one primary code for the first interspace through each skin incision and AOCs for each additional interspace through the same skin incision.
· Fluoroscopy reported as CPT code 76000 shall not be reported with spinal procedures, unless there is a specific “CPT Manual” instruction indicating that it is separately reportable. For some spinal procedures, there are specific radiologic guidance codes to report in lieu of these fluoroscopy codes. For other spinal procedures, fluoroscopy is used in lieu of a more traditional intraoperative radiologic examination which is included in the operative procedure. For other spinal procedure codes, fluoroscopy is integral to the procedure. (CPT code 76001 was deleted January 1, 2019.)
· CPT code 38220 describes diagnostic bone marrow aspiration(s). It shall not be reported separately with musculoskeletal procedures (e.g., spinal osteotomy, vertebral fracture repair, spinal arthrodesis, spinal fusion, laminectomy, spinal decompression, and vertebral corpectomy), for bone marrow aspiration for platelet rich stem cell injection, or other therapeutic musculoskeletal applications.
· CPT code 38220 describes diagnostic bone marrow aspiration(s). It shall not be reported separately with musculoskeletal procedures (e.g., spinal osteotomy, vertebral fracture repair, spinal arthrodesis, spinal fusion, laminectomy, spinal decompression, and vertebral corpectomy), for bone marrow aspiration for platelet rich stem cell injection, or other therapeutic musculoskeletal applications.
· CPT codes 38230 (Bone marrow harvesting for transplantation; allergenic) and 38232 (Bone marrow harvesting for transplantation; autologous) shall not be reported separately with a spinal osteotomy, vertebral fracture repair, spinal arthrodesis, spinal fusion, spinal laminectomy, spinal decompression, or vertebral corpectomy CPT code for procurement of bone marrow aspirate. CPT codes 38230 and 38232 are used to report the procurement of bone marrow for future bone marrow transplantation.
· CMS payment policy does not allow separate payment for CPT codes 63042 (Laminotomy…; lumbar) or 63047 (Laminectomy…; lumbar) with CPT codes 22630 or 22633 (Arthrodesis; lumbar) when performed at the same interspace. If the 2 procedures are performed at different interspaces, the 2 codes of an edit pair may be reported with modifier 59 or XS.
· Only one anterior or posterior instrumentation CPT code (e.g., CPT codes 22840- 22847) may be reported through a single skin incision.
· CPT codes 22853 and 22854 describe insertion of interbody biomechanical device(s) into intervertebral disc space(s). Integral anterior instrumentation to anchor the device to the intervertebral disc space when performed is not separately reportable. It is a misuse of anterior instrumentation CPT codes (e.g., 22845-22847) to report this integral anterior instrumentation. However, additional anterior instrumentation (i.e., plate, rod) unrelated to anchoring the device may be reported separately appending an NCCI-associated modifier such as modifier 59 or XU.
12. The PTP edit with Column One CPT code 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar) and Column Two CPT code 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)) consists of 2 CPT codes with code descriptors representing different surgeries. The edit indicates that the 2 procedures shall not be reported together at the same anatomic site (spinal level) at the same patient encounter. A provider/supplier shall not use modifiers 59 or -X {ES} to bypass this edit unless the 2 procedures are performed at separate anatomic sites (i.e., different spinal levels) or separate patient encounters on the same date of service.
Bone graft (20930-20938)
• Autograft – Graft from one site to another site of the same individual.
• Allograft – Graft from a donor of the same species. Some times from Cadaver.
• Bone graft can be reported with main procedures
• Morselized (The process of dividing into small portions)
• During the spine fusion surgery same incision or a separate incision is made to remove bone graft from the patient’s body (Usually iliac bone, Ribs or spine) called Harvesting
62 modifier to spine procedure
• Do not report 62 modifier to instrumentation codes (22840-22848, 22850-22852, 22853, 22854, 22859)
• Do not report 62 modifier to bone graft (20930-20938)
• 62 modifier can be reported with main procedures (Arthrodesis, Kyphectomy ect.,)
Reinsertion of spinal fixation (22849)
• Reinsertion of spinal or removal is reported with other definitive procedures, including arthordesis, decompression and exploration of fusion if it different spinal level with 51 modifier.
• Do not report 22849 to definitive procedures when performed in different spinal level
51 modifier within the definitive procedure
When arthrodesis is performed in addition to another procedure the arthrodesis should be reported in addition to the original procedure with modifier 51
Other definitive procedures are
• Osteotomy,
• fracture care
• Vertebral corpectomy
• Laminectomy
Coding tips
• Number definitive procedure to append 51 modifier
• Two surgeon involved 62?
• Instrumentation (Anterior or posterior, number of vertebrae )
• Bone graft (Auto, allo, mor, struc?)
• Same incision to single level or different incision.
• Sequencing
• Includes and excludes
Example: 1
A 42 year old male with a history of posttraumatic degenerative disc disease at L3-L4 and L4-L5 (internal disc disruption) underwent surgical repair. Surgeon A performed an anterior exposure of the spine with mobilization of the great vessels. Surgeon B performed anterior discectomy and fusion at L3-L4 and L4-L5 using anterior interbody technique.
Surgeon A: 22558- 62, 22585-62
Surgeon B: 22558-62, 22585-62, 20931
Example: 2
Posterior arthrodesis of L4-S1, utilizing morselized autogenous iliac bone graft harvested through separate fascial incision and pedicle screw fixation.
22612, 22614, 22842, 20937
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