MAY 2014

Pitfalls in Spinal Arthrodesis Coding

When I first started coding spinal arthrodesis procedures the techniques that were performed and the implants used were of a standard variety, but all of that has changed in the past few years with the advent of new techniques, minimally invasive procedures and development of new types of implants known as cages.  Not to confuse anyone because cages have been around for a long time, but now there are what’s called “stand-alone” or “low profile” cages which will be explained further below.

So let’s start from the beginning and the first thing you look for in the dictation is the technique (approach) for the procedure and whether or not a decompression procedure is performed such as a laminotomy or laminectomy during lumbar fusions. PITFALL—when performing an interbody arthrodesis (22630) or a combined interbody and posterior/posterolateral arthrodesis (22633) then your decompression procedure codes such as laminotomy/laminectomy (63030, 63042, 63047, 63056) are all bundled per CCI edits so these services would not be additionally reported for any carriers following CCI edit guidelines.

One approach uses what’s called the METRx system. This is a percutaneously placed tube through which the procedure is performed using an operating microscope. PITFALL—this is considered one of the minimally invasive techniques but still uses the open CPT codes for reporting purposes.

Once the approach and decompression procedure has been performed an interbody cage may be placed which is usually reported with CPT code 22851.  The definition of this code reads “biomechanical device(s)” such as PEEK cages. PITFALL—I have seen dictation where it is indicated that a “biomechanical device” was used but in the body of the op note it states “the graft was placed”. Structural allograft bone implants are coded using bone graft codes and not 22851 – biomechanical device. If unsure confirm the type of device being placed.  Also, these devices are reported one time per vertebral level. For example; 2 cages placed at L4-L5 would be coded as 22851, whereas 1 cage at L4-L5 and 1 cage at L5-S1 would be coded as 22851 and 22851 with either modifier -59 or -76 depending on your carrier’s guidelines. 

Let’s go back to the “stand-alone” or “low profile” cages. Once an interbody device has been placed instrumentation in the form of a plate and screws can be used to stabilize/supplement the fusion site. PITFALL—There are new cages that come with screws that go directly through the cages to hold them in place. For the purposes of coding, when a cage is placed followed by a separate plate and screws then you can report both 22851 and the appropriate instrumentation code. When the cage already comes with associated screws or fixation then you would only report code 22851. Some examples of these devices are Stalif, LDR cage, Prevail or Sovereign (this is not an all-inclusive list) so the coder must recognize or know the type of device being placed in order to code correctly.

Lastly, many times bone marrow is harvested and mixed with allograft and/or autograft and then is packed in the cage or around boney surfaces. PITFALL—The harvesting is reported as 38220 and although this code bundles per CCI edits there is a CCI edit guideline that allows this code to be reported with modifier -59 as long as the bone marrow is harvested from a separate site.

Spinal arthrodesis surgeries are considered high dollar volume procedurestake every opportunity to make sure you are familiar with the latest coding guidelines for maximizing reimbursement!




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