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A surgeon performs an arthrodesis of lumbar vertebrae L1–L2. What are the appropriate codes to report for this procedure? Would it be CPT® code 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) or code 22612 and add-on code 22614 (each additional vertebral segment)? A surgeon performing a... |
To a spinal surgeon, a segment is two movable units. To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take in... |
To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take into account the reason for the fusion
When coding a sp... |
Take into account the reason for the fusion
When coding a spinal fusion, consider the reason for the procedure. Review the documentation to determine whether the physician performed the fusion for deformity, pain, or instability, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for The ... |
For a fusion for spinal deformity (e.g., scoliosis or kyphosis), coders should look to codes 22800–22819. This code series was created for, and intended to be used for, fusion procedures performed on younger patients with congenital spinal deformities, not for degenerative scoliosis, says Stumpf. If the surgeon is perf... |
If the surgeon is performing the fusion for pain or instability, coders should reference one of the following code series:
- 22532–22534 (lateral extracavitary)
- 22548–22585 (anterior or anterolateral)
- 22590–22632 (posterior)
Identify the approach used in the procedure
Surgeons can use various approaches when perfor... |
Also note that if the physician documents “direct lateral approach” for spinal fusion, coders should code it as an anterior approach per the North American Spinal Society and the American Association of Neurological Surgeons. Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of th... |
Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of the fusion procedure. Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biom... |
Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biomechanical device, such as:
- Polyether ether ketone (PEEK) devices (e.g., Mosaic, LDR, GraftCage, Capstone, Zero-P... |
Note that coders should report code 22851 per interspace or vertebral defect, not per device, says Pollock. Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders... |
Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders should report it using code 22851, Stumpf says. Report all structural allografts using code 20931, so they ... |
Think of an allograft as bone in a bottle or a package. Coders should report all bone graft codes only once per surgery with, Pollock says. The bone graft codes include:
- 20930 (allograft or osteopromotive material for spine surgery, morselized)
- 20931 (allograft for spine surgery, structural)
- 20936 (autograft, loc... |
But note that some carriers—Medicare and private payers who follow Medicare guidelines—will not pay for the use of a microscope, Stumpf says. However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Co... |
However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Coding Initiative (NCCI) edits, she says. CPT guidelines instruct coders to report the microscope use, and CPT lists specific codes with which i... |
However, NCCI edits bundle the microscope into the procedure code. To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the ... |
To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the use of a microscope for a discectomy or laminectomy, Pollock adds. ... |
Coders should report the use of the microscope even when the payer won’t reimburse for it because it is an appropriate CPT combination. Medicare also sometimes reverses the NCCI edits, Pollock adds. “If you didn’t bill for it originally, you won’t be able to file for a redetermination.”
When the surgeon uses a microsco... |
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at email@example.com. Interested in learning more about spinal coding? Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services and Kristi Stumpf, MCS-P, CPC, COSC, ACS-O... |
A surgeon performs an arthrodesis of lumbar vertebrae L1–L2. What are the appropriate codes to report for this procedure? Would it be CPT® code 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) or code 22612 and add-on code 22614 (each additional vertebral segment)? A surgeon performing a... |
To a spinal surgeon, a segment is two movable units. To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take in... |
To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take into account the reason for the fusion
When coding a sp... |
Take into account the reason for the fusion
When coding a spinal fusion, consider the reason for the procedure. Review the documentation to determine whether the physician performed the fusion for deformity, pain, or instability, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for The ... |
For a fusion for spinal deformity (e.g., scoliosis or kyphosis), coders should look to codes 22800–22819. This code series was created for, and intended to be used for, fusion procedures performed on younger patients with congenital spinal deformities, not for degenerative scoliosis, says Stumpf. If the surgeon is perf... |
If the surgeon is performing the fusion for pain or instability, coders should reference one of the following code series:
- 22532–22534 (lateral extracavitary)
- 22548–22585 (anterior or anterolateral)
- 22590–22632 (posterior)
Identify the approach used in the procedure
Surgeons can use various approaches when perfor... |
Also note that if the physician documents “direct lateral approach” for spinal fusion, coders should code it as an anterior approach per the North American Spinal Society and the American Association of Neurological Surgeons. Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of th... |
Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of the fusion procedure. Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biom... |
Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biomechanical device, such as:
- Polyether ether ketone (PEEK) devices (e.g., Mosaic, LDR, GraftCage, Capstone, Zero-P... |
Note that coders should report code 22851 per interspace or vertebral defect, not per device, says Pollock. Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders... |
Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders should report it using code 22851, Stumpf says. Report all structural allografts using code 20931, so they ... |
Think of an allograft as bone in a bottle or a package. Coders should report all bone graft codes only once per surgery with, Pollock says. The bone graft codes include:
- 20930 (allograft or osteopromotive material for spine surgery, morselized)
- 20931 (allograft for spine surgery, structural)
- 20936 (autograft, loc... |
But note that some carriers—Medicare and private payers who follow Medicare guidelines—will not pay for the use of a microscope, Stumpf says. However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Co... |
However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Coding Initiative (NCCI) edits, she says. CPT guidelines instruct coders to report the microscope use, and CPT lists specific codes with which i... |
However, NCCI edits bundle the microscope into the procedure code. To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the ... |
To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the use of a microscope for a discectomy or laminectomy, Pollock adds. ... |
Coders should report the use of the microscope even when the payer won’t reimburse for it because it is an appropriate CPT combination. Medicare also sometimes reverses the NCCI edits, Pollock adds. “If you didn’t bill for it originally, you won’t be able to file for a redetermination.”
When the surgeon uses a microsco... |
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at email@example.com. Interested in learning more about spinal coding? Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services and Kristi Stumpf, MCS-P, CPC, COSC, ACS-O... |
A surgeon performs an arthrodesis of lumbar vertebrae L1–L2. What are the appropriate codes to report for this procedure? Would it be CPT® code 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) or code 22612 and add-on code 22614 (each additional vertebral segment)? A surgeon performing a... |
To a spinal surgeon, a segment is two movable units. To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take in... |
To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take into account the reason for the fusion
When coding a sp... |
Take into account the reason for the fusion
When coding a spinal fusion, consider the reason for the procedure. Review the documentation to determine whether the physician performed the fusion for deformity, pain, or instability, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for The ... |
For a fusion for spinal deformity (e.g., scoliosis or kyphosis), coders should look to codes 22800–22819. This code series was created for, and intended to be used for, fusion procedures performed on younger patients with congenital spinal deformities, not for degenerative scoliosis, says Stumpf. If the surgeon is perf... |
If the surgeon is performing the fusion for pain or instability, coders should reference one of the following code series:
- 22532–22534 (lateral extracavitary)
- 22548–22585 (anterior or anterolateral)
- 22590–22632 (posterior)
Identify the approach used in the procedure
Surgeons can use various approaches when perfor... |
Also note that if the physician documents “direct lateral approach” for spinal fusion, coders should code it as an anterior approach per the North American Spinal Society and the American Association of Neurological Surgeons. Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of th... |
Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of the fusion procedure. Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biom... |
Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biomechanical device, such as:
- Polyether ether ketone (PEEK) devices (e.g., Mosaic, LDR, GraftCage, Capstone, Zero-P... |
Note that coders should report code 22851 per interspace or vertebral defect, not per device, says Pollock. Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders... |
Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders should report it using code 22851, Stumpf says. Report all structural allografts using code 20931, so they ... |
Think of an allograft as bone in a bottle or a package. Coders should report all bone graft codes only once per surgery with, Pollock says. The bone graft codes include:
- 20930 (allograft or osteopromotive material for spine surgery, morselized)
- 20931 (allograft for spine surgery, structural)
- 20936 (autograft, loc... |
But note that some carriers—Medicare and private payers who follow Medicare guidelines—will not pay for the use of a microscope, Stumpf says. However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Co... |
However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Coding Initiative (NCCI) edits, she says. CPT guidelines instruct coders to report the microscope use, and CPT lists specific codes with which i... |
However, NCCI edits bundle the microscope into the procedure code. To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the ... |
To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the use of a microscope for a discectomy or laminectomy, Pollock adds. ... |
Coders should report the use of the microscope even when the payer won’t reimburse for it because it is an appropriate CPT combination. Medicare also sometimes reverses the NCCI edits, Pollock adds. “If you didn’t bill for it originally, you won’t be able to file for a redetermination.”
When the surgeon uses a microsco... |
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at email@example.com. Interested in learning more about spinal coding? Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services and Kristi Stumpf, MCS-P, CPC, COSC, ACS-O... |
A surgeon performs an arthrodesis of lumbar vertebrae L1–L2. What are the appropriate codes to report for this procedure? Would it be CPT® code 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) or code 22612 and add-on code 22614 (each additional vertebral segment)? A surgeon performing a... |
To a spinal surgeon, a segment is two movable units. To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take in... |
To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take into account the reason for the fusion
When coding a sp... |
Take into account the reason for the fusion
When coding a spinal fusion, consider the reason for the procedure. Review the documentation to determine whether the physician performed the fusion for deformity, pain, or instability, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for The ... |
For a fusion for spinal deformity (e.g., scoliosis or kyphosis), coders should look to codes 22800–22819. This code series was created for, and intended to be used for, fusion procedures performed on younger patients with congenital spinal deformities, not for degenerative scoliosis, says Stumpf. If the surgeon is perf... |
If the surgeon is performing the fusion for pain or instability, coders should reference one of the following code series:
- 22532–22534 (lateral extracavitary)
- 22548–22585 (anterior or anterolateral)
- 22590–22632 (posterior)
Identify the approach used in the procedure
Surgeons can use various approaches when perfor... |
Also note that if the physician documents “direct lateral approach” for spinal fusion, coders should code it as an anterior approach per the North American Spinal Society and the American Association of Neurological Surgeons. Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of th... |
Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of the fusion procedure. Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biom... |
Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biomechanical device, such as:
- Polyether ether ketone (PEEK) devices (e.g., Mosaic, LDR, GraftCage, Capstone, Zero-P... |
Note that coders should report code 22851 per interspace or vertebral defect, not per device, says Pollock. Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders... |
Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders should report it using code 22851, Stumpf says. Report all structural allografts using code 20931, so they ... |
Think of an allograft as bone in a bottle or a package. Coders should report all bone graft codes only once per surgery with, Pollock says. The bone graft codes include:
- 20930 (allograft or osteopromotive material for spine surgery, morselized)
- 20931 (allograft for spine surgery, structural)
- 20936 (autograft, loc... |
But note that some carriers—Medicare and private payers who follow Medicare guidelines—will not pay for the use of a microscope, Stumpf says. However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Co... |
However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Coding Initiative (NCCI) edits, she says. CPT guidelines instruct coders to report the microscope use, and CPT lists specific codes with which i... |
However, NCCI edits bundle the microscope into the procedure code. To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the ... |
To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the use of a microscope for a discectomy or laminectomy, Pollock adds. ... |
Coders should report the use of the microscope even when the payer won’t reimburse for it because it is an appropriate CPT combination. Medicare also sometimes reverses the NCCI edits, Pollock adds. “If you didn’t bill for it originally, you won’t be able to file for a redetermination.”
When the surgeon uses a microsco... |
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at email@example.com. Interested in learning more about spinal coding? Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services and Kristi Stumpf, MCS-P, CPC, COSC, ACS-O... |
A surgeon performs an arthrodesis of lumbar vertebrae L1–L2. What are the appropriate codes to report for this procedure? Would it be CPT® code 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) or code 22612 and add-on code 22614 (each additional vertebral segment)? A surgeon performing a... |
To a spinal surgeon, a segment is two movable units. To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take in... |
To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take into account the reason for the fusion
When coding a sp... |
Take into account the reason for the fusion
When coding a spinal fusion, consider the reason for the procedure. Review the documentation to determine whether the physician performed the fusion for deformity, pain, or instability, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for The ... |
For a fusion for spinal deformity (e.g., scoliosis or kyphosis), coders should look to codes 22800–22819. This code series was created for, and intended to be used for, fusion procedures performed on younger patients with congenital spinal deformities, not for degenerative scoliosis, says Stumpf. If the surgeon is perf... |
If the surgeon is performing the fusion for pain or instability, coders should reference one of the following code series:
- 22532–22534 (lateral extracavitary)
- 22548–22585 (anterior or anterolateral)
- 22590–22632 (posterior)
Identify the approach used in the procedure
Surgeons can use various approaches when perfor... |
Also note that if the physician documents “direct lateral approach” for spinal fusion, coders should code it as an anterior approach per the North American Spinal Society and the American Association of Neurological Surgeons. Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of th... |
Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of the fusion procedure. Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biom... |
Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biomechanical device, such as:
- Polyether ether ketone (PEEK) devices (e.g., Mosaic, LDR, GraftCage, Capstone, Zero-P... |
Note that coders should report code 22851 per interspace or vertebral defect, not per device, says Pollock. Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders... |
Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders should report it using code 22851, Stumpf says. Report all structural allografts using code 20931, so they ... |
Think of an allograft as bone in a bottle or a package. Coders should report all bone graft codes only once per surgery with, Pollock says. The bone graft codes include:
- 20930 (allograft or osteopromotive material for spine surgery, morselized)
- 20931 (allograft for spine surgery, structural)
- 20936 (autograft, loc... |
But note that some carriers—Medicare and private payers who follow Medicare guidelines—will not pay for the use of a microscope, Stumpf says. However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Co... |
However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Coding Initiative (NCCI) edits, she says. CPT guidelines instruct coders to report the microscope use, and CPT lists specific codes with which i... |
However, NCCI edits bundle the microscope into the procedure code. To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the ... |
To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says. Also remember that CPT guidelines do not prohibit coders from reporting the use of a microscope for a discectomy or laminectomy, Pollock adds. ... |
Coders should report the use of the microscope even when the payer won’t reimburse for it because it is an appropriate CPT combination. Medicare also sometimes reverses the NCCI edits, Pollock adds. “If you didn’t bill for it originally, you won’t be able to file for a redetermination.”
When the surgeon uses a microsco... |
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at email@example.com. Interested in learning more about spinal coding? Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services and Kristi Stumpf, MCS-P, CPC, COSC, ACS-O... |
A surgeon performs an arthrodesis of lumbar vertebrae L1–L2. What are the appropriate codes to report for this procedure? Would it be CPT® code 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) or code 22612 and add-on code 22614 (each additional vertebral segment)? A surgeon performing a... |
To a spinal surgeon, a segment is two movable units. To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take in... |
To a coder, a segment indicates one bone. So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612. Take into account the reason for the fusion
When coding a sp... |
Take into account the reason for the fusion
When coding a spinal fusion, consider the reason for the procedure. Review the documentation to determine whether the physician performed the fusion for deformity, pain, or instability, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for The ... |
For a fusion for spinal deformity (e.g., scoliosis or kyphosis), coders should look to codes 22800–22819. This code series was created for, and intended to be used for, fusion procedures performed on younger patients with congenital spinal deformities, not for degenerative scoliosis, says Stumpf. If the surgeon is perf... |
If the surgeon is performing the fusion for pain or instability, coders should reference one of the following code series:
- 22532–22534 (lateral extracavitary)
- 22548–22585 (anterior or anterolateral)
- 22590–22632 (posterior)
Identify the approach used in the procedure
Surgeons can use various approaches when perfor... |
Also note that if the physician documents “direct lateral approach” for spinal fusion, coders should code it as an anterior approach per the North American Spinal Society and the American Association of Neurological Surgeons. Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of th... |
Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of the fusion procedure. Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biom... |
Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biomechanical device, such as:
- Polyether ether ketone (PEEK) devices (e.g., Mosaic, LDR, GraftCage, Capstone, Zero-P... |
Note that coders should report code 22851 per interspace or vertebral defect, not per device, says Pollock. Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace. Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders... |
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