2015 Spinal Procedure Coding Reference

12 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 2015 Spinal Procedure Coding Reference COMPUTER ASSISTED SURGERY (CAS) 00.31 CAS with CT/CTA 00.32 CAS with MR/MRA 00.33 CAS with fluoroscopy 00.34 Imageless CAS 00.35 CAS with multiple datasets 00.39 Other CAS 61783 Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure) Computer-assisted surgery (CAS) is an adjunct to surgery that works like a global positioning system for the surgeon. This technology superimposes the position of the instruments as they are used in surgery onto images of the patient s anatomy displayed on a computer monitor. As the surgeon moves an instrument in the patient s body, sensors calculate its position, and then transfer the data to a computer within the operating room. The surgeon relies on these images to confirm the position of the instruments as the surgery proceeds. The coordinated use of imaging, intra-operative sensing and computer workstations allows increased visualization and precise, accurate navigation through minimally invasive approaches. No assigned; Status Indicator N Payments packaged with other services. 2005, 4th qtr 2004, 4th qtr 2008, 4th qtr 2013, 4th qtr January 2006 October 2008 October 2001 October October 2008 2010 June 2000 October July 2010 2011 November 1999 November 2009 The CAS codes are always assigned in addition to the ICD-9-CM code for the primary procedure. Example: Laminectomy using CAS with fluoroscopic-guided navigation Codes: 03.09 decompression of spinal canal 00.33 computer-assisted surgery with fluoroscopy As defined, the CAS codes are assigned according to the type of imaging used. The specific application is identified by the code for the primary procedure. Code 00.39 is assigned if the type of imaging used in CAS is not known or not documented. Likewise, for CPT, Code 61783 is an add-on and is always assigned in addition to the CPT code for the primary spinal procedure.

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 13 EXPLORATION OF SPINAL FUSION 03.09 Other exploration and decompression of spinal canal 22830 Exploration of spinal fusion No assigned; Status Indicator C Inpatient Only This procedure is performed to explore the site of a previous spinal fusion. The approach (anterior, posterior, or posterolateral) varies based on how the original fusion was performed. The physician makes an incision over the site of the previous fusion and retracts fascia and paravertebral muscles. The instrumentation, wiring, and grafts of the fusion site are explored and adjusted, replaced or removed if needed. If decompression of the spinal canal is needed, the physician also removes bony tissue or overgrowth around the lamina or foramen. This may be performed bilaterally. 722.81 Postlaminectomy syndrome, cervical region 722.82 Postlaminectomy syndrome, thoracic region 722.83 Postlaminectomy syndrome, lumbar region 724.2 Thoracic or lumbosacral neuritis or radiculitis unspecified 733.13 Pathologic fracture of vertebrae 733.81 Mal-union of fracture 733.82 Non-union of fracture 996.4 Mechanical complication of internal orthopedic device, implant, and graft 996.67 Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft 996.78 Other complications due to other internal orthopedic device, implant, and graft V45.4 Arthrodesis status 2013, 3rd qtr 2011, 2nd qtr 2008, 4th qtr 2008, 2nd qtr 2002, 2nd and 4th qtr 2000, 2nd qtr 1999, 4th qtr 1995, 2nd qtr 1990, 2nd qtr November 1998 September 1997 February 1996 March 2010 May 2012 for HCPCS 2009, 3rd qtr

14 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE LAMINECTOMY 03.09 Other exploration and decompression of spinal canal 63001 63017, 63045 63048 Laminectomy is performed to correct such spinal pathology as spondylolisthesis, radiculitis, neuritis, sciatic pain and spinal stenosis by decompressing the spinal cord. The procedure is performed by posterior approach with an incision made over the affected vertebrae. The paravertebral muscles are retracted followed by removal of the spinous process and interspinous ligament. The surgeon excises the lamina and the ligamentum flavum may also be removed. Overgrowth of bony tissue may be removed, thus allowing decompression of the dural sac and nerve roots. Gelfoam or free-fat grafts may be placed over the exposed nerve roots. In those cases where the ligamentum flavum has not been removed, it may be placed over the fat graft upon closure. A drain is placed in the superficial layers and the fascia, subcutaneous and skin layers are closed. 721.0 Cervical spondylosis without myelopathy 721.1 Cervical spondylosis with myelopathy 721.2 Thoracic spondylosis without myelopathy 721.41 Spondylosis with myelopathy, thoracic region 721.83 Postlaminectomy syndrome, lumbar region 723.0 Spinal stenosis in cervical region 723.4 Brachial neuritis or radiculitis, NOS 724.01 Spinal stenosis of thoracic region 724.02 Spinal stenosis of lumbar region, without neurogenic claudication 724.03 Spinal stenosis of lumbar region, with neurogenic claudication 724.1 Pain in thoracic spine 724.3 Sciatica 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 0208; Status Indicator T Significant Procedure, Multiple Reduction Applies 63001-63017 63045-63047 No assigned; Status Indicator N, Payment packaged with other services 63048 2013, 2nd qtr 2011, 2nd qtr 2008, 2nd and 4th qtr 2004, 3rd qtr 2002, 2nd and 4th qtr 2000, 2nd qtr 1999, 4th qtr 1997, 2nd qtr 1995, 2nd qtr December 2014 December 2013 December 2012 June 2012 July 2012 January 2012 November 2010 November and September 2002 February 2001 January and November 1999 March and April 1996 January 2001 for HCPCS 2014, 1st qtr 2009, 3rd qtr Illustration: Do not code if considered the operative approach. Should not be coded with code 80.51 if performed at the same operative site.

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 15 LAMINOPLASTY 03.09 Other exploration and decompression of spinal canal 63050 Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments 63051 With reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices, when performed) No assigned; Status Indicator C Inpatient Only A cervical laminoplasty is performed for severe cervical spinal stenosis. This procedure is indicated when conservative non-operative treatment measures have failed with severe neurologic symptoms such as myelopathy. Once asleep and positioned in the operating room, the nurse will cleanse the back of the neck with antiseptic solution. This procedure is performed with intraoperative neurologic monitoring. The surgeon will make an incision on the back of the neck and dissect the tissues in order to access the spine. The spinal level is identified and verified with intraoperative X-rays. Under magnification, the bony arches of the cervical spine are then surgically opened (like a door hinge) to expose the lining over the spinal cord. This maneuver decompresses the previously crushed spinal cord. This bony hinge is secured in place with small portions of cadaveric bone that act as struts. The deep tissues are sutured back into anatomic alignment. The skin is closed with a plastic surgical closure. 2004, 3rd qtr 2002, 2nd qtr 2000, 2nd qtr 1999, 4th qtr 1995, 2nd qtr Insider s View 2005 723.0 Spinal stenosis in cervical region

16 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE REOPENING OF LAMINECTOMY ICD-9 Procedure Codes 03.02 Reopening of laminectomy site 63040 63044 Reopening of a previously performed laminectomy is sometimes needed to treat spondylosis, degenerative disc, postlaminectomy syndrome, and other disorders. An incision is made over the previous laminectomy site and the paravertebral muscles are retracted. The ligamentum flavum, if not removed in the prior laminectomy, may be partially or completely removed. The lamina that was previously left on the opposite side is then removed or more of the lamina from the original site may be removed. The spinal cord is now easily accessed in order to ascertain etiology of patient s symptoms such as a ruptured disc or disc fragments. Another cause of compression of the nerve may be bony tissue around the foramen or a facet, both of which may be excised during this procedure. Once decompression is complete, a free-fat graft may be placed over the nerve root and possibly covered with the ligamentum flavum. The paravertebral muscles are repositioned and the procedure completed with layered closure of the superficial tissues. 721.0 Cervical spondylosis without myelopathy 721.1 Cervical spondylosis with myelopathy 721.3 Lumbosacral spondylosis without myelopathy 721.42 Spondylosis with myelopathy, lumbar region 722.4 Degeneration of cervical intervertebral disc 722.52 Degeneration of lumbar or lumbrosacral intervertebral disc 722.81 Postlaminectomy syndrome, cervical region 722.83 Postlaminectomy syndrome, lumbar region 723.0 Spinal stenosis in cervical region 723.4 Brachial neuritis or radiculitis, NOS 724.02 Spinal stenosis of lumbar region, without neurogenic claudication 724.03 Spinal stenosis of lumbar region, with neurogenic claudication 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 756.12 Congenital spondylolisthesis 0208; Status Indicator T Significant Procedure, Multiple Reduction Applies 63040 63042 No assigned; Status Indicator N Payment packaged with other services 63043 63044 1999, 4th qtr September 2002 January 2001 and February 2001 November 1999 and January 1999

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 17 CORDOTOMY 03.21 Percutaneous cordotomy 03.29 Other cordotomy 63170 63200 Anterolateral cordotomy involves severing the pain-conducting nerve fibers on one or both sides of the spinal cord. Cordotomy provides the selective loss of pain and temperature perception several segments below and contralateral to the segment at which the incision is performed or where the ablative lesion (if done percutaneously with radiofrequency ablation) is placed. The surgeon makes an incision over the affected vertebrae, incises the fascia and retracts the paravertebral muscles. A laminectomy is carried out and the surgeon identifies the anterolateral tracts on the side lying opposite the pain. The dentate ligament is divided at the cordotomy level and the ligament is moved posteriorly toward the midline in order to expose the anterolateral portion of the cord. A cordotomy knife is used to divide the tissue anterior to the dentate ligament and in front of the anterior spinal artery. The incision is closed in a layered fashion. No assigned; Status Indicator C Inpatient Only NA September 2002 February 2001 November 1999 333.83 Spasmodic torticollis 334.1 Hereditary spastic paraplegia 343.0 Diplegic infantile cerebral palsy 343.8 Other specified infantile cerebral palsy 343.9 Unspecified infantile cerebral palsy 724.1 Pain in thoracic spine 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 729.2 Unspecified neuralgia, neuritis and radiculitis 781.0 Abnormal involuntary movements 781.7 Tetany

18 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE EXCISION/DESTRUCTION OF LESION OF THE SPINE 03.4 Excision or destruction of lesion of spinal cord or spinal meninges 63265 63290 and 63300 63308 No assigned; Status Indicator C Inpatient Only An abscess, cyst or other spinal growth often requires removal or destruction. The patient is placed in the prone position for a posterior approach. The surgeon makes a midline incision, incises the fascia and retracts the paravertebral muscles. The laminae and spinous process are removed in order to expose the dura. The dura is incised as well as the pia-arach. 324.1 Intraspinal abscess 349.2 Disorders of meninges, not elsewhere classified 2013, 3rd qtr 2008, 2nd qtr 1995, 3rd qtr NA for HCPCS 2010, 2nd qtr

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 19 ALLOGRAFT FOR SPINAL SURGERY 78.09 Bone graft to specified bone, except facial bone 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) 20931 Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) An allograft is a tissue graft taken from one human being and placed into another. Also called a homograft, an allograft is obtained from a cadaver and preserved through freezing or other methods until needed. A bone allograft is often utilized in spinal procedures, and involves preparation and insertion by the surgeon. No assigned; Status Indicator N Payment packaged with other services NA February 1996 January 2004 April 2012 July 2011 December 2007 February 2008 for HCPCS 2010, 2nd qtr Allograft is not reported separately, it is included in the fusion code for ICD-9-CM In CPT, the allograft codes are add-ons and always assigned in addition to the CPT code for the primary spinal procedure. Illustration: CORNERSTONE ASR Allograft Implant CORNERSTONE Select

20 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE AUTOGRAFT FOR SPINE SURGERY ICD-9-CM Procedure codes 77.79 Excision of bone for graft, other, pelvic bones, phalanges (of foot) (of hand), vertebrae 20936 Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) 20937 Morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) 20938 Structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) An autograft is tissue taken from the patient and re-inserted into a different anatomical site in that same patient. Autografts are used for vertebral fusion and other spinal procedures. The surgeon obtains the bone graft by making an incision over bony sites near the skin surface such as the ilium or fibula. The surgeon may use a saw, chisel, or knife to obtain the bone autograft and then prepare the graft for implantation. No assigned; Status Indicator C Inpatient Only 2013, 2nd qtr 2008, 1st qtr 2002, 2nd qtr and 4th qtr 2000, 2nd qtr January 2004 July 2011 September 1997 December 2011 March 1996 April 2012 February 2008 July 2013 Locally harvested bone can be reported using 77.79

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 21 REMOVAL OF SPINAL INSTRUMENTATION 78.69 Removal of implanted device from other bone 22850 Removal of posterior nonsegmental instrumentation (e.g., Harrington rod) 22852 Removal of posterior segmental instrumentation 22855 Removal of anterior instrumentation Spinal instrumentation is used to stabilize the spine for fusion or to correct a deformity. Over time, certain circumstances may require that the instrumentation be removed. During this procedure, the physician makes an incision over the area of instrumentation and removes bone and collagen, thus exposing the instrumentation. The superior hook or screw is then loosened and disconnected from the vertebra. This is followed by disconnection of the inferior and segmental hooks from the vertebrae and removal of the hardware. 996.4x Mechanical complication of internal orthopedic device, implant, and graft 996.67 Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft 996.78 Other complications due to other internal orthopedic device, implant, and graft V45.4 Arthrodesis status V54.01 Aftercare involving removal of fracture plate or other internal fixation device No assigned; Status Indicator C Inpatient Only 2002, 4th qtr 2000, 2nd qtr 2007, 4th qtr June 2012 November 2004 February 2002 and November 2002 November 1999 November 1998 September 1997 May 2006

22 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE PARTIAL OSTECTOMY (VERTEBRAE, SPINOUS PROCESS, LAMINA, OR FACET) 77.89 Other partial ostectomy, other, pelvic bones, phalanges (of foot) (of hand), vertebrae 22100 22116 for partial excision of posterior vertebral component/body. A partial ostectomy involves the surgical excision of a portion of bone. In this procedure, the physician incises the fascia and retracts the paravertebral muscles over the affected vertebrae. The physician then performs the ostectomy by excising a portion of the spinous process, lamina or facet. 170.2 Malignant neoplasm of vertebral column, excluding sacrum and coccyx 198.5 Secondary malignant neoplasm of bone and bone marrow 213.2 Benign neoplasm of vertebral column, excluding sacrum and coccyx 238.0 Neoplasm of uncertain behavior of bone and articular cartilage 239.2 Neoplasms of unspecified nature of bone, soft tissue, and skin 721.5 Kissing spine 723.0 Spinal stenosis in cervical region 724.01 Spinal stenosis in thoracic region 724.02 Spinal stenosis of lumbar region, without neurogenic claudication 724.03 Spinal stenosis of lumbar region, with neurogenic claudication 733.21 Solitary bone cyst 733.22 Aneurysmal bone cyst 733.29 Other cyst of bone 208; Status Indicator T Significant Procedure, Multiple Reduction Applies 22100 22101 22102 No assigned; status Indicator N Payment packaged with other services 22103 No assigned; Status Indicator C Inpatient Only 22110 22116 1999, 4th Quarter November 1998 January 2003

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 23 WEDGE OSTEOTOMY OF THE SPINE 77.29 Wedge osteotomy of bone, other, pelvic bones, phalanges (of foot) (of hand), vertebrae 22210 22226 for Osteotomy of spine Various surgical approaches may be used when performing this procedure depending on the approach needed. The surgeon excises a wedge shaped section of bone above and below the vertebrae, thus correcting the pathologically deformed spine. Instrumentation and bone grafting may also be utilized in this straightening procedure, followed by closure of the muscle and subcutaneous layers. 720.0 Ankylosing spondylitis 733.13 Pathologic fracture of vertebrae 737.10 Kyphosis (acquired) (postural) 737.20 Lordosis (acquired) (postural) 737.30 Scoliosis (and Kyphoscoliosis), idiopathic 738.5 Other acquired deformity of back or spine 756.12 Congenital spondylolisthesis 756.15 Congenital fusion of spine (vertebra) 905.1 Late effect of fracture of spine and trunk without mention of spinal cord lesion 907.2 Late effect of spinal cord injury No assigned; Status Indicator C Inpatient Only 22210 22226 NA December 2014 December 2007 November 1998 December 1997 for HCPCS 2009, 4th qtr

24 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE REPAIR OF VERTEBRAL FRACTURE OR DISLOCATION 79.39 Open reduction of fracture with internal fixation, other specified bone 79.89 Open reduction of dislocation of other specified sites 03.53 Repair of vertebra fracture 22305 22315 for closed treatment of vertebral fractures 22325 22328 for open treatment and/or reduction of vertebral fractures and/or dislocations The physician prepares the operative site by incision and retraction of skin, fascia, and paravertebral muscle layers overlying the injured vertebral site. A rod is inserted and anatomic or C-shaped hooks are aligned on the vertebrae above and below the fractured site. This procedure stabilizes or fixates the vertebral fracture for proper alignment in healing. 733.13 Pathologic fracture of vertebrae 733.81 Mal-union of fracture 733.82 Non-union of fracture 805.00 Closed fracture of cervical vertebra, unspecified level without mention of spinal cord injury 805.10 Open fracture of cervical vertebra, unspecified level without mention of spinal cord injury 805.2 Closed fracture of dorsal (thoracic) vertebra without mention of spinal cord injury 805.3 Open fracture of dorsal (thoracic) vertebra without mention of spinal cord injury 805.4 Closed fracture of lumbar vertebra without mention of spinal cord injury 805.5 Open fracture of lumbar vertebra without mention of spinal cord injury 839.00 Closed dislocation, unspecified cervical vertebra 839.10 Open dislocation, unspecified cervical vertebra 839.20 Closed dislocation, lumbar vertebra 839.21 Closed dislocation, thoracic vertebra 839.30 Open dislocation, lumbar vertebra 839.31 Open dislocation, thoracic vertebra Status Indicator T Significant Procedure, Multiple Reduction applies 22305 ( 129) 22310 ( 138) 22315 ( 431) No assigned; Status Indicator C Inpatient Only 22325 22328 2007, 1st qtr 2003, 2nd qtr 2002, 2nd qtr 2000, 2nd qtr 1999, 3rd and 4th qtr 1996, 3rd qtr 1994, 2nd qtr June 2006 July 2014 February 1996 April 2012

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 25 DISCECTOMY 80.51 Excision of intervertebral disc 63020 63044 and 63075 63078 A discectomy is performed to remove all or a portion of a herniated intervertebral disc. The patient is placed in a supine position and the head stabilized with head halter traction in order to perform the procedure. A transverse incision is made over the affected disc and the sternocleidomastoid muscle and carotid artery are retracted. The surgeon then excises the anterior annulus of the disc and uses pituitary forceps to remove disc material. A spreader and operating microscope are used as well to evacuate the disc material. 721.0 Cervical spondylosis without myelopathy 721.1 Cervical spondylosis with myelopathy 721.2 Thoracic spondylosis without myelopathy 721.41 Spondylosis with myelopathy, thoracic region 721.8 Other allied disorders of spine 722.11 Displacement of thoracic intervertebral disc w/o myelopathy 722.51 Degeneration of thoracic or thoracolumbar intervertebral disc 722.72 Intervertebral thoracic disc disorder with myelopathy, thoracic region 722.83 Postlaminectomy syndrome, lumbar region 722.92 Other and unspecified disc disorder of thoracic region 723.0 Spinal stenosis in cervical region 723.04 Brachial neuritis or radiculitis NOS 724.01 Spinal stenosis of thoracic region 724.02 Spinal stenosis of lumbar region, without neurogenic claudication 724.03 Spinal stenosis of lumbar region, with neurogenic claudication 724.1 Pain in thoracic spine 724.3 Sciatica 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 754.2 Congenital musculoskeletal deformity of spine 952.10 T1 T6 level spinal cord injury, unspecified 0208; Status Indicator T Significant Procedure, Multiple Reduction Applies 63020-63030, 63040-63042 63075 No assigned; status indicator N payment packaged with other services 63035 63043-63044 63076 No assigned; Status Indicator C Inpatient Only 63077-63078 1996, 1st qtr 1995, 2nd qtr 1990, 2nd qtr 2006, 1st qtr 2007, 1st qtr 2008, 2nd and 1st qtr 2008, 4th qtr 2009, 2nd qtr December 2013 December 2012 July 2012 November 2010 February and September 2002 January and February 2001 January and November 1999 for HCPCS 2012, 3rd qtr 2011, 2nd qtr 2009, 3rd qtr 2008, 2nd qtr ICD-9-CM code includes that by laminotomy and hemilaminectomy Requires additional code for any concomitant decompression of spinal nerve root at different level from excision site. Per, 1st quarter 2007, when a corpectomy is performed in conjunction with a discectomy, the discectomy is included in the corpectomy code 80.99 other excision of joint of other specified site and is not separately reported.

26 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE Illustration: Skin Subcutaneous Tissue Spinous Process Fascia (thin membrane surrounding each muscle) Lamina (Removal of this portion of bone is a laminectomy) Muscle Fascia Disc

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 27 ARTHRODESIS Spinal Fusions 81.00 Spinal fusion, NOS 81.01 Atlas-axis fusion 81.02 Other cervical fusion of the anterior column, anterior technique 81.03 Other cervical fusion of the posterior column, posterior technique 81.04 Dorsal and dorsolumbar fusion of the anterior column, anterior technique 81.05 Dorsal and dorsolumbar fusion of the posterior column, posterior technique 81.06 Lumbar and lumbosacral fusion of the anterior column, anterior technique 81.07 Lumbar and lumbosacral fusion of the posterior column, posterior technique 81.08 Lumbar and lumbosacral fusion of the anterior column, posterior technique Spinal Refusions 81.30 Refusion of spine, NOS 81.31 Refusion of atlas-axis spine 81.32 Refusion of other cervical spine, anterior column, anterior technique 81.33 Refusion of other cervical spine, posterior column, posterior technique 81.34 Refusion of dorsal and dorsolumbar spine, anterior column, anterior technique 81.35 Refusion of dorsal and dorsolumbar spine, posterior column, posterior technique 81.36 Refusion of lumbar and lumbosacral spine, anterior column, anterior technique 81.37 Refusion of lumbar and lumbosacral spine, posterior column, posterior technique 81.38 Refusion of lumbar and lumbosacral spine, anterior column, posterior technique 81.39 Refusion of spine, not elsewhere classified Multi-level Spinal Fusion Procedures 81.62 Fusion or refusion of 2 3 vertebrae 81.63 Fusion or refusion of 4 8 vertebrae 81.64 Fusion or refusion of 9 or more vertebrae See 22532 22534, 22548 22586, 22590 22634, 22800 22812, 0195T-0196T, 0309T 721.0 Cervical spondylosis without myelopathy 721.1 Cervical spondylosis with myelopathy 721.2 Thoracic spondylosis without myelopathy 721.41 Spondylosis with myelopathy, thoracic region 722.83 Postlaminectomy syndrome, lumbar region 723.0 Spinal stenosis in cervical region 723.4 Brachial neuritis or radiculitis nos 724.01 Spinal stenosis of thoracic region 724.02 Spinal stenosis of lumbar region, without neurogenic claudication 724.03 Spinal stenosis of lumbar region, with neurogenic claudication 724.1 Pain in thoracic spine 724.3 Sciatica 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 0425; Status Indicator J1 Comprehensive, All other services packaged and not separately payable 22612 22551 22554 No assigned; Status Indicator N payment packaged with other services 22614 No assigned; Status Indicator C Inpatient only 22532-22548 22800-22812 22552 22556-22610 22630-22634 0195T-0196T 0309T 2007, 1st qtr 2009, 2nd qtr 2003, 4th qtr 2008, 2nd qtr, 1st qtr 2002, 2nd and 4th qtr 2010, 4th qtr 2001, 4th qtr 2013, 2nd qtr 2000, 2nd qtr January 2003 October 2009 Feb. and April 2002 June 2012 January 2001 January 2012 September 2000 December 2011 Nov. and Dec. 1999 November 2011 September 1997 November 2010 February 1996 ICD-9-CM: Spinal Fusion codes include placing the bone graft and spinal instrumentation (eg. screws, rods, plates) Code also the harvesting of bone graft 77.79 Code also any interbody spinal fusion device (84.51) Code also recombinant bone morphogenetic protein (84.52) Code also the total number of vertebrae fused (81.62 81.64) CPT: Although codes 22612, 22614 and 22554 are approved in the outpatient setting, many spinal procedures are not. Please check the inpatient only list. Code also instrumentation codes, if applicable Code also bone graft codes, if applicable Code also interbody device, if applicable Additionally, check CCI edits to ensure proper coding.

28 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE PERCUTANEOUS VERTEBROPLASTY 81.65 Percutaneous vertebroplasty 22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic 22511 Lumbosacral 22512 Each additional cervicothoracic or lumbosacral vertebral body Percutaneous vertebroplasty is a therapeutic, interventional radiologic procedure that consists of an injection of a biomaterial into a cervical, thoracic, or lumbar vertebral body lesion for the relief of pain and the strengthening or stabilizing of bone. The skin and underlying tissues are anesthetized with lidocaine and a special bone needle is passed slowly through the pedicle into the vertebral body using a slightly angled posterior approach. When the needle is in appropriate position, a small test injection with x-ray contrast is performed to ensure that a vein has not been entered. This prevents the inadvertent passage of cement into a vein and embolization to the heart and lungs. The needle is repositioned if necessary and the cement mixture is slowly injected during constant x-ray monitoring. When the potential spaces within the vertebral body are filled, the needle is slowly removed and the other half of the vertebral body is then filled with material. 170.2 Malignant neoplasm of vertebral column, excluding sacrum coccyx 198.5 Secondary malignant neoplasm of bone and bone marrow 203.00 Multiple myeloma without mention of remission 203.01 Multiple myeloma in remission 213.2 Benign neoplasm of vertebral column, excluding sacrum and coccyx 239.2 Neoplasms of unspecified nature of bone, soft tissue, and skin 252.00 Hyperparathyroidism, unspecified 255.0 Cushing s syndrome 721.2 Thoracic spondylosis without myelopathy 721.3 Lumbosacral spondylosis without myelopathy 733.13 Pathologic fracture of vertebrae 805.2 Closed fracture of dorsal (thoracic) vertebra without mention of spinal cord injury 805.4 Closed fracture of lumbar vertebra without mention of spinal cord injury. 0050; Status Indicator T Significant Procedure, Multiple Reduction Applies 22510-22511 No assigned; status indicator N Payment packaged with other services 22512 2004, 4th qtr 2002, 2nd qtr 2008, 2nd qtr 2012, 4th qtr October 2006 Insider s View 2015 March 2001 June 2012 In ICD-9-CM, if vertebral biopsy is performed report code 77.49 in addition to code 81.65 In CPT, vertebral biopsy is included and is not coded separately For outpatient procedures, see codes 72291 and 72292 for radiological supervision and interpretation.

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 29 PERCUTANEOUS VERTEBRAL AUGMENTATION 81.66 Percutaneous vertebral augmentation 22513 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty) inclusive of all imaging guidance; thoracic 22514 Lumbar 22515 Each additional thoracic or lumbar vertebral body 0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device when used, 1or more needles, includes imaging guidance and bone biopsy when performed 0201T Percutaneous sacral augmentation (sacroplasty), bilateral injection(s), including the use of a balloon or mechanical device when used, 2 or more needles, includes imaging guidance and bone biopsy when performed Vertebral augmentation, similar to vertebroplasty, is another minimally-invasive procedure used to treat vertebral compression fractures. Using fluoroscopic or CT guidance, a bone tamp is inserted into the vertebral body to create a void within the body. The defect produced by the tamp is filled with a bone cement. This procedure is usually performed under general or monitored anesthesia. The bone cement is injected using low pressure. 170.2 Malignant neoplasm of vertebral column, excluding sacrum coccyx 198.5 Secondary malignant neoplasm of bone and bone marrow 203.00 Multiple myeloma without mention of remission 203.01 Multiple myeloma in remission 213.2 Benign neoplasm of vertebral column, excluding sacrum and coccyx 239.2 Neoplasms of unspecified nature of bone, soft tissue, and skin 252.00 Hyperparathyroidism, unspecified 255.0 Cushing s syndrome 721.2 Thoracic spondylosis without myelopathy 721.3 Lumbosacral spondylosis without myelopathy 733.13 Pathologic fracture of vertebrae 805.2 Closed fracture of dorsal (thoracic) vertebra without mention of spinal cord injury 805.4 Closed fracture of lumbar vertebra without mention of spinal cord injury 0052; Status Indicator T Significant Procedure, Multiple Reduction Applies 22513-22514 No assigned; status indicator N Payment packaged with other services 22515 2006, 3rd qtr 2004, 4th qtr 2002, 2nd qtr 2007, 1st qtr 2008, 2nd qtr October 2006 June 2012 Insider s View 2015 In ICD-9-CM, if vertebral biopsy is performed report code 77.49 in addition to code 81.65 In CPT, vertebral biopsy is included and is not coded separately For outpatient procedures, see codes 72291 and 72292 for radiological supervision and interpretation.

30 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE INJECTION FOR SACROILIAC JOINT 81.92 Injection of therapeutic substance into joint or ligament 99.23 Injection of steroid 99.29 Injection or infusion of other therapeutic or prophylactic substance 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT), including arthrography when performed The sacroiliac joint is the articulation between the sacrum and the innominate bone of the pelvis. In this procedure, the physician injects the sacroiliac joint with contrast, anesthetic and/or a steroid. A syringe is utilized through a posterior approach to inject the sacroiliac joint. Fluoroscopic or CT guidance may be utilized for guidance of the needle during the sacroiliac injection. 715.09 Generalized osteoarthrosis, involving multiple sites 715.15 Primary localized osteoarthrosis, pelvic region and thigh 716.15 Traumatic arthropathy, pelvic region and thigh 718.25 Pathological dislocation of pelvic region and thigh joint 719.45 Pain in joint, pelvic region and thigh 719.85 Other specified disorders of pelvic joint 755.69 Other congenital anomaly of lower limb, including pelvic girdle 805.6 Closed fracture of sacrum and coccyx without mention of spinal cord injury 805.7 Open fracture of sacrum and coccyx without mention of spinal cord injury 808.41 Closed fracture of ilium 808.43 Multiple closed pelvic fractures with disruption of pelvic circle 808.51 Open fracture of ilium 808.53 Multiple open pelvic fractures with disruption of pelvic circle 839.42 Closed dislocation, sacrum 839.52 Open dislocation, sacrum No assigned; Status Indicator B Not recognized under OPPS 2010, 3rd qtr 1999, 1st qtr 2000, 3rd qtr April 2004 April 2003 November 1999 November 1998 July 2008 January 2012

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 31 BONE MORPHOGENETIC PROTEIN 84.52 Insert of recombinant bone morphogenetic protein (rhbmp) 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (list separately in addition to code for primary procedure) Arthrodesis is the surgical immobilization or fusion of a joint. Arthodesis of the spine is performed for disorders such as degenerative or displaced disc, spondylosis, kyphosis, pathologic or traumatic fractures, dislocations, and other spinal disorders. Treatment of such conditions may involve arthrodesis to stabilize the spine. Code selection for the arthrodesis procedure is dependent upon the surgical approach used. If multiple approaches are utilized, each should be coded separately. The bone morphogenetic proteins (BMP) (rhbmp-2) are used as bone graft replacements and must be surgically implanted. BMP is approved for single level anterior lumbar interbody fusion using the INFUSE Bone Graft/LT-CAGE Lumbar Tapered Fusion Device technology. The product is placed at the fusion site to promote bone growth. This is done in place of the more traditional use of autogenous iliac crest bone graft, therefore acting as a substitute for harvesting of autogenous bone. No assigned; Status Indicator N Payment packaged with other services. 2002, 4th qtr 2009, 2nd qtr April 2012 for HCPCS 2010, 3rd qtr Code also primary procedure code (i.e. spinal fusion or spinal refusion) Effective January 1, 2011, the code description for 20930 was revised to include placement of osteopromotive material. Therefore, bone morphogenetic protein (rhbmp) is reported with code 20930.

32 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE INSERTION OF INTERBODY SPINAL FUSION DEVICE 84.51 Insertion of interbody spinal fusion device 22851 Application of intervertebral biomechanical device(s), (e.g., synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure) No assigned; status indicator N Payment packaged with other services 2004, 1st qtr 2007, 1st qtr 2003, 2nd qtr 2008, 2nd qtr 2002, 1st qtr and 4th qtr 2009, 2nd qtr 2000, 2nd qtr February 2005 June 2007 May 2000 December 2011 September 1997 November 2014 In ICD-9-CM, code 84.51 includes: Insertion of cages Interbody fusion cage Synthetic cage or spacers Threaded bone dowels Illustration: CLYDESDALE SPINAL SYSTEM CRESENT SPINAL SYSTEM AFFINITY Anterior Cervical Cage System

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 33 INTERSPINOUS PROCESS DEVICE 84.80 Insertion or replacement of interspinous process device(s) 84.81 Revision of interspinous process device(s) Category III codes implemented January 2007 0171T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level 0172T each additional level The IPD usually can be performed using a local anesthetic with light intravenous sedation, with the patient in the lateral decubitus or prone position. A posterior, 4-8 cm midline incision is made exposing the spinous processes at the appropriate disc level, which is confirmed radiographically. The supraspinous ligament is typically preserved. The interspinous ligament is dilated and the IPD implant is inserted and implanted without fixation to bones or ligaments. Implantation of the IPD is usually under 60 minutes for a single level implant. 721.0 Cervical spondylosis without myelopathy 721.1 Cervical spondylosis with myelopathy 721.2 Thoracic spondylosis without myelopathy 721.41 Spondylosis with myelopathy, thoracic region 722.83 Postlaminectomy syndrome, lumbar region 723.0 Spinal stenosis in cervical region 723.4 Brachial neuritis or radiculitis nos 724.01 Spinal stenosis of thoracic region 724.02 Spinal stenosis of lumbar region, without neurogenic claudication 724.03 Spinal stenosis of lumbar region, with neurogenic claudication 724.1 Pain in thoracic spine 724.3 Sciatica 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 0425; Status Indicator J1 Comprehensive, all other services packaged and not separately payable 0171T No assigned; status indicator N Payment packaged with other services 0172T 2005, 4th qtr 2007, 4th qtr December 2006 December 2013 July 2007 October 2014 for HCPCS 2009, 2nd qtr Illustration: SPINAL PROCEDURES REFERENCE X-STOP INTERSPINOUS SPACER SYSTEM The diagnosis codes shown represent possible conditions that physicians may chose to treat with spinal disc prostheses. This list is not necessarily limited to the FDA indication for any specific device or product. Provision of these codes is informational only and not intended to promote the product outside of its approved indication.

34 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE INSERTION OF SPINAL DISC PROSTHESIS 84.59 Insertion of other spinal devices 84.60 Insertion of spinal prosthesis, not otherwise specified 84.61 Insertion of partial spinal disc prosthesis, cervical 84.62 Insertion of total spinal disc prosthesis, cervical 84.63 Insertion of spinal disc prosthesis, thoracic 84.64 Insertion of partial spinal disc prosthesis, lumbosacral 84.65 Insertion of total spinal disc prosthesis, lumbosacral 84.66 Revision or replacement of artificial spinal disc prosthesis, cervical 84.67 Revision or replacement of artificial spinal disc prosthesis, thoracic 84.68 Revision or replacement of artificial spinal disc prosthesis, lumbosacral 84.69 Revision or replacement of artificial spinal disc prosthesis, not otherwise specified 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical +22858 second level, cervical 0375T Total disc arthoplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels 22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single, interspace, cervical 0095T Each additional interspace 22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace, cervical 0098T Each additional interspace 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace 0163T Each additional interspace 22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, lumbar, single interspace 0165T Each additional interspace 22865 Removal of total disc arthroplasty (artificial disc), anterior approach, lumbar, single interspace 0164T Each additional interspace Replacement of Total Disc Artificial disc replacement is designed to restore the normal disc height (the same purpose a cage serves in spinal fusion) by replacing the damaged intervertebral disc with a mobile implant. There are several types of artificial discs being studied including those fabricated from combinations of metal, polyethylene, polyurethane, and other biomaterials. The surgical procedure for the total disc prosthesis places an implant using the anterior approach. Using a retroperitoneal approach the midline was identified and the anterior annulus as excised. A discectomy is performed to the posterior longitudinal ligament. After adequate discectomy the prosthesis was impacted into place. Partial Disc Replacement Nucleus Replacement Device The nucleus replacement device is designed to replace the degenerated nucleus and restore the normal disc function and anatomy thereby decreasing the stress redistributed to adjacent levels of the spine. This should lead to an interruption of the degenerative cascade and offer a less invasive treatment option to fusion and a treatment that could be used earlier in the degenerative process. Historically patients undergoing fusion surgery have poor return to work results. Allowing the patient an earlier treatment option could have significant return to work and positive daily living ramifications. It should also be noted that this early treatment option does not eliminate the fusion option later in the disease state. This is because the procedure does not involve destruction of healthy anatomy by removal of bony elements, damage to endplate structures or removal of the circumferential annulus. This leaves further treatment options open and facilitates an easy revision procedure if necessary.

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 35 INSERTION OF SPINAL DISC PROSTHESIS (Continued) 170.2 Malignant neoplasm of vertebral column, excluding sacrum and coccyx 198.6 Secondary malignant neoplasm of bone and bone marrow 722.11 Displacement of lumbar intervertebral disc without myelopathy 722.53 Degeneration of lumbar or lumbosacral intervertebral disc 722.74 Intervertebral lumbar disc disorder with myelopathy, lumbar region 722.84 Postlaminectomy syndrome, lumbar region 732.0 Juvenile osteochondrosis of spine 724.02 Spinal stenosis of lumbar region, without neurogenic claudication 724.03 Spinal stenosis of lumbar region, with neurogenic claudication 733.14 Pathologic fracture of vertebrae 738.0 Adolescent postural kyphosis 737.10 Kyphosis (acquired) (postural) 737.21 Lordosis (acquired) (postural) 737.32 Scoliosis (and kyphoscoliosis) idiopathic 737.33 Resolving infantile idiopathic scoliosis 756.14 Congenital spondylolysis, lumbosacral region 737.35 Scoliosis due to radiation 737.36 Thoracogenic scoliosis 737.44 Unspecified curvature of spine associated with other condition 737.45 Kyphosis associated with other condition 737.46 Lordosis associated with other condition 737.47 Scoliosis associated with other condition 737.9 Other curvatures of spine associated with other conditions 738.6 Other acquired deformity of back or spine 754.3 Congenital musculoskeletal deformity of spine 756.15 Congenital spondylolisthesis 756.16 Absence of vertebrae, congenital 805.4 Closed fracture of lumbar vertebra without mention of spinal cord injury 805.5 Open fracture of lumbar vertebra without mention of spinal cord injury 806.6 Closed fracture of lumbar spine with spinal cord injury 806.7 Open fracture of lumbar spine with spinal cord injury 839.21 Closed dislocation, lumbar vertebra 0425; Status Indicator J1 Comprehensive, all other services packaged and not separately payable 22856 No assigned; Status Indicator C Inpatient Only 22857-22865 0095T-0098T 0163T-0165T 0375T 2004, 4th qtr 2002, 4th qtr 2007, 4th qtr June 2007 Insider s View 2006, 2007,2009, 2015 Examples: PRESTIGE Cervical Disc BRYAN Cervical Disc CHARITE Lumbar Disc Illustration: PRESTIGE Cervical Disc BRYAN Cervical Disc The diagnosis codes shown represent possible conditions that physicians may chose to treat with spinal disc prostheses. This list is not necessarily limited to the FDA indication for any specific device or product. Provision of these codes is informational only and not intended to promote the product outside of its approved indication.

36 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE INSERTION OF BONE VOID FILLER 84.55 Insertion of Bone Void Filler No CPT code assigned NA There has been significant work on the development of synthetic products to use in filling bony voids. These synthetic products lack the properties needed for promoting bone growth. However, they eliminate many of the complications from bone graft procurement and difficulties of acquiring enough graft to fill large voids. Many of the synthetic products in use today include calcium-based materials, which offer greater absorption qualities that allow bone growth to slowly replace the absorbed synthetic materials. There are several types of cement that can be used as alternatives to autologous bone grafts. Polymethylmethacrylate cement (PMMA) cement is used to mold into a defect. PMMA is composed of acrylic cement that never goes away. Therefore, no new bone can form in its place. Injectable osteoconductive calcium phosphate cements have been introduced as an adjunct to internal fixation for treating selected fractures. These cements develop high compressive strength, share the compressive load of the fracture with the local bone, and are then remodeled slowly into new bone. The main purpose of the cement is to fill voids in metaphyseal bone (bone adjacent to a joint), thereby reducing the need for bone graft. The surgeon prepares the bony void and then mixes the cement injection. The surgeon then has three minutes to inject the bone void cement into the void. 2004, 4th qtr NA Example: MASTERGRAFT

2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE 37 MANIPULATION OF SPINE 93.29 Other forcible correction of musculoskeletal deformity 22505 Manipulation of spine requiring anesthesia, any region 0045; Status Indicator T Significant Procedure, Multiple Reduction Applies Manipulation of the spine is often used to treat fractures and dislocations of the spine. This procedure is performed under general anesthesia and involves application of halo or tongs to the skull. Traction is applied to the halo or tongs and feet, thus decompressing the vertebrae. The weights used in traction are adjusted until the appropriate correction of the spine is accomplished. Traction is then removed and followed by immobilization of the patient. 722.93 Other and unspecified disc disorder of lumbar region 723.5 Torticollis, unspecified 724.3 Lumbago 724.4 Sciatica 728.85 Spasm of muscle 729.2 Unspecified neuralgia, neuritis, and radiculitis 739.4 Nonallopathic lesion of sacral region, not elsewhere classified 839.00 Closed dislocation, unspecified cervical vertebra 839.20 Closed dislocation, lumbar vertebra 839.21 Closed dislocation, thoracic vertebra 839.42 Closed dislocation, sacrum 847.0 Neck sprain and strain 953.0 Injury to cervical nerve root 956.0 Injury to sciatic nerve 996.4 Mechanical complication of internal orthopedic device, implant, and graft NA January 1999 November 1998 March 1997

38 2014 HOSPITAL CODING MANUAL CHAPTER 5: 2014 SPINAL PROCEDURE REFERENCE PEDICLE-BASED DYNAMIC STABILIZATION ICD-9-CM Procedure codes 84.82 Insertion or replacement of pedicle-based dynamic stabilization device(s) 84.83 Revision of pedicle-based dynamic stabilization device(s) 22899 Unlisted Procedure, Spine (no specific CPT code) This procedure is performed to treat pain due to stenosis and/or spondylolisthesis. It is pedicle-screw based and provides posterior stabilization with or without decompression and provides normal loading across the disc. 724.01 Spinal stenosis of thoracic region 724.02 Spinal stenosis of lumbar region, without neurogenic claudication 724.03 Spinal stenosis of lumbar region, with neurogenic claudication 724.1 Pain in thoracic spine 724.3 Sciatica 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 0050; Status Indicator T Significant Procedure, Multiple Reduction Applies 2007, 4th qtr 2011, 2nd qtr NA for HCPCS 2010, 3rd qtr 2010, 1st qtr In ICD-9-CM, these codes exclude: Initial insertion of pedicle screws with spinal fusion omit code Insertion or replacement of facet replacement device(s) (84.84) Revision of facet replacement device(s) (84.85) Insertion or replacement of interspinous process device(s) (84.80) Revision of interspinous process device(s) (84.81) Replacement of pedicle screws used in spinal fusion (78.59) Example: Dynesys Spinal System