Spine Surgery Coding: Don t Break Your Neck Trying to Figure It Out

Spine Surgery Coding: Don t Break Your Neck Trying to Figure It Out Presented to: AAPC Annual Meeting Orlando, Florida April 15, 2013 Presented by: Kim Pollock, RN, MBA, CPC www.karenzupko.com

Kim Pollock, RN, MBA, CPC Consultant and Speaker Kim Pollock specializes in streamlining the operations of neurosurgical practices. Kim has thirty years experience in health care as a nurse, administrator and consultant. For over thirteen years, Ms. Pollock has helped large group practices, as well as academic and solo practices, improve collections and efficiency. She is expert at auditing neurosurgery coding and documentation. Ms. Pollock understands the complexity of coding and reimbursement issues specific to neurological surgeons both from a clinical perspective and from a payor side. She is an expert in analyzing chart documentation and in reengineering practices to enhance the reimbursement process. She has presented seminars and workshops for physicians and their staff on behalf of the American Association of Neurological Surgeons and the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS). Ms. Pollock has also conducted programs for the American Academy of Procedural Coders, the North American Spine Society, the American Neurotology Society and the Congress of Neurological Surgeons. Based on her previous years of administrative experience, Ms. Pollock has a unique understanding of the challenges facing academic medicine both clinically and organizationally. She has served as the Administrator of the Department of Otorhinolaryngology as well as Associate Vice President of Cancer Programs at the University of Texas Southwestern Medical School in Dallas. Ms. Pollock was the representative for the AAO-HNS on the clinical practice expert paneltechnical group (CPEP-TEG) convened by CMS (formerly HCFA) to redetermine the practice expense portion of RBRVS. She served two terms on the Board of Directors for the Society of Otorhinolaryngology and Head-Neck Nurses, Inc. (SOHN) and has served on the Board for the Ear, Nose and Throat Nursing Foundation. Ms. Pollock is the recipient of the prestigious Presidential Citation Award from the SOHN as well as an Honor Award from the AAOHNS. Ms. Pollock holds a Masters of Business Administration Degree as well as a Bachelors of Science Degree in Nursing. She is also a certified coder through the AAPC. KZA Disclaimer This manual is not intended to provide legal advice to physicians and their staffs. If you have specific questions regarding the permissibility of your billing or other practices, we recommend that you consult legal counsel directly for assistance in evaluating any legal, regulatory or compliance issues regarding these matters. In the event that you choose to consult with outside legal counsel, KZA is available to work with such counsel, as appropriate, to meet your needs. CPT five digit codes, nomenclature and other data are copyright 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. 2

Global Surgical Package Surgical CPT Code Preoperative Period Intraoperative Time Postoperative Global Period Incision and Approach Resection or Repair Closure Exception: The skull base surgery codes consider an approach and definitive codes as separate stand-alone codes. Pre-op Period Intra-op Service Post-op Period CPT Says Subsequent to the decision for surgery, one related E&M encounter on the date immediately prior to or on the date of procedure (including history and physical) Local infiltration, metacarpal/ metatarsal/digital block or topical anesthesia. Moderate (conscious) sedation may be reported as indicated in CPT Immediate postoperative care, including dictating operative notes, talking with the family and other physicians Writing orders Evaluating the patient in the postanesthesia recovery area Pain management services Intraoperative nerve monitoring by the surgeon Typical follow-up care Medicare Says E&M in which the decision is made is separately billable. Visits to perform history and physicals are not separately reportable. Major procedure has a preoperative global period of day before and day of the procedure Minor procedure has a preoperative global period of the day of the procedure Anesthesia of any kind given by the operating surgeon. Exception: moderate (conscious) sedation may be reported by the surgeon when appropriate. Discussion with patient/family about the nature of the procedure, alternative treatment risks, benefits and other informed consent issues Scheduling surgery Writing preoperative admission notes and orders Dictating the operative record Writing postoperative orders and postoperative prescribed care Postoperative pain management including catheter placement by operating surgeon Intraoperative nerve monitoring by the surgeon Follow-up care including treatment of complications unless they require a return to the operating room for the prescribed follow-up period Major procedure has a postoperative global period of 90 days Minor procedure has a postoperative global period of 0 or 10 days Remember: Placement of a pain delivery catheter is not separately reportable for the surgeon (not even using an unlisted code). 3

Global Surgical Package CAN I BILL FOR A PREOP VISIT? From CPT Assistant, May 2009: Q: Are preoperative visits billable? If so, what code should be used and what is the time frame before surgery to submit this code? A: If the decision for surgery occurs on the day of or day before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision making service, not the history and physical (H&P) alone. If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package. POSTOP PERIODS FOR COMMON SPINE PROCEDURES The following tables are not a complete listing of Medicare s postoperative global periods refer to a Medicare resource for other CPT codes. Also, check with your non-medicare payors to see if they follow Medicare s guidelines. 0-Day Global Period CPT Description 20660 Placement of cranial tongs 62311 Epidural steroid injection 10-Day Global Period* CPT Description 22520-22522 Vertebroplasty 22523-22525 Vertebral augmentation 62350 Place epidural catheter 62362 Placement of spine infusion pump 63650 Placement of epidural neurostimulator array *Note: The intent of a 10-day global period is that the first postoperative visit is included and not separately reported. Remember: Add-on codes (e.g., 69990, 20930, 22840) are not subject to a global period. 90-Day Global Period CPT Description 63xxx Laminectomy, corpectomy codes 22xxx Arthrodesis codes 4

Global Surgical Package CPT Says The CPT codes that represent a readily identifiable surgical procedure. AANS Says 1. Positioning the patient and stabilizing the head after arrival in the operating room. 2. Preparation of the surface area to be used for the surgical exposure, which includes removal of hair, shaving the skin and marking the area for incision. 3. Infiltration of any local anesthetic and/or vasoconstrictive agents into the part to be incised, when the procedure is performed under general anesthesia. 4. Surgical approach to the area when not otherwise covered by a separate approach procedure code (e.g., skull base approach codes 61580-61598), with identification and protection of regional anatomic structures, to include hemostasis and nerve stimulation. 5. Wound management techniques including use of wound irrigation, wound cultures, and placement and removal of surgical drainage or suction devices. 6. Use of imaging techniques during the procedure, including fluoroscopy, x-rays, angiography, and ultrasonography and including supervision or direction of such techniques. (Imaging is included unless otherwise specified to code it separately.) 7. Use of special surgical adjuncts such as the laser or ultrasonic aspirating device. 8. Use of data from electronic monitoring of cerebral potentials (EEG, evoked potentials) or motor evoked potentials with intraoperative EMG. 9. Use of magnification with loupes. 10. Closure of the operative wound with repair of the operative tract. 11. Application of dressings, braces, splints or casts including traction where appropriate. 12. Takedown of the patient from operative positioning and fixation devices with transfer to a bed or gurney. AANS says basic services EXCLUDED from the global service package include: 1. Placement of additional and/or special devices preparatory to initiation of surgery, i.e., placement of a lumbar drain catheter for spinal fluid drainage during craniotomy. 2. Application of halo or other complex fixation or traction devices to the skull in the operating room if not just for operative use. 3. Placement of a twist drill or burr hole for ventricular puncture that is followed by other surgery (61105, 61120) or for implanting a ventricular catheter before surgery (61107, 61210). This is to be excluded if done in a separate location to the craniotomy (opposite side or different setting). 4. Microdissection by use of an operating microscope (69990) for intracranial or spinal procedures for structures and pathology that are so small as not easily seen without use of the microscope for dissection and illumination of dural or intradural lesions (except 22551, 22552, 61548, 63075-63078, 64727, and 64820-64823). Code 69990 may be reported with spine procedure codes (e.g., 63001-63051, 63081-63103). 5. Complicated wound closure requiring mobilization of scalp or skin flaps and/or skin graft (13160, 13300, 14000-14350, 15000-15400, 15570-15576, 61618-61619). 6. Treatment for the underlying condition or an added course of treatment, which is not part of the normal recovery from surgery. 7. Clearly distinct surgical procedures during the postoperative period or staged procedures. 8. Critical care services (codes 99291 and 99292) unrelated to the surgery. Note: The American Academy of Orthopaedic Surgery (AAOS) global service guide has similar guidelines. 5

Principles of Spine Procedure Coding Bone Graft Allograft vs. autograft Morselized vs. structural Instrumentation Location: anterior vs. posterior vs. intervertebral Remember: There are some bundled decompression/ discectomy and fusion codes (e.g., 22551) so don t unbundle and bill separately (e.g., 63075 and 22554). Arthrodesis Approach: anterior vs. posterior vs. lateral extracavitary vs. pre-sacral Region: cervical vs. thoracic vs. lumbar Decompression (e.g., laminectomy, discectomy, corpectomy, spine fracture repair) Approach: anterior vs. posterior vs. lateral extracavitary Region: cervical vs. thoracic vs. lumbar Any other procedures performed? Examples: 1) Microdissection (+69990) 2) Stereotactic navigational planning (+61783) 3) Bone marrow aspirate (38220) through a separate needle puncture site (e.g., via iliac crest for cervical procedure) or documented separate skin/fascial incision. 6

Posterior Spine Instrumentation Codes: +22840, +22842 - +22844 Posterior Instrumentation: Code based on the # of attachments and # of segments spanned CPT CPT Description Code +22840 Posterior non-segmental instrumentation (e.g., Harrington rod technique), pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation +22842 Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminal wires); 3 to 6 vertebral segments +22843 7 to 12 vertebral segments +22844 13 or more vertebral segments +22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) +22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) Coding Only 2 points of attachment regardless of # of vertebral segments spanned More than 2 points of attachment. Count # of vertebral segments spanned. Use when performed alone; do not report 22841 in addition to 22840, 22842-22844 e.g., iliac wing rods/screws/bolts; typically used in deformity correction procedures Updated in 2013: The combined arthrodesis codes 22633 and 22634 have been added to the inclusionary parenthetical notes following 22840-22848 and 22851, indicating that 22633 and 22634 may be reported in conjunction with these codes. Examples of Instrumentation 1. L5-S1 pedicle screws and rods 2. L3-L4-L5 pedicle screws and rods 3. L3-L5 pedicle screws and rods (with nothing at L4 due to fracture) Code 4. Pedicle screws and rods at L1-2, L2-3, L3-4, L4-5, L5-S1 5. Lateral mass screws at C2-C3 *Appropriate decompression, fusion and bone graft codes may be separately reported as documented in the operative note. CPT Says: Do not append modifier 62 to spinal instrumentation codes 22840-22848. Beware CMS payment policy still allows modifier 62! Remember: All spinal instrumentation codes are add-on codes (billed and reimbursed at 100%). 7

Anterior Instrumentation Codes (+22845 - +22847) 1 ST segment 2 ND segment 3 vertebral segments = 22845 3 RD segment CPT Code CPT Description +22845 Anterior instrumentation; 2 to 3 vertebral segments +22846 4 to 7 vertebral segments +22847 8 or more vertebral segments Anterior Instrumentation: Code based on the number of vertebral segments spanned. Alert: The anterior instrumentation must be a device that crosses an interspace and can provide support and stand alone in order to separately report 22845. Do not report 22845 in addition to 22851 for low profile intervertebral devices with attached plates/buttress screws or a device that cannot provide independent stabilization on its own. Intervertebral Device Code: +22851 Examples: Polyether ether ketone (PEEK), titanium, expandable cage, carbon fiber CPT Code CPT Description +22851 Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), methylmethacrylate) to vertebral defect or interspace Placement of methylmethacrylate around the pedicle screws in a patient with sever osteoporosis, to reinforce the instrumentation, is not separately reported with 22851 or any other code. This is considered part of the instrumentation code (e.g., 22840). Off-label use for insertion mesh bag filled with cement in an interspace may be reported using 22851. If percutaneously placed in the interspace, use 22899 (Unlisted procedure, spine). Use 22851 for open kyphoplasty where cement injected into vertebral body during an open procedure. 8

Bone Graft Codes (+20930 - +20938) CPT Says: Do not append modifier 62 to bone graft codes 20930-20938. Remember: All bone graft codes are add-on codes (billed and reimbursed at 100%). CPT Description Code +20930 Allograft, morselized or placement of osteopromotive materials 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) +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) Each bone graft code may be reported once per operative session (not once per spinal interspace or per side). There is no code for reconstruction of the iliac crest defect after graft harvest this activity is included in 20937 or 20938. Off-label use for insertion mesh bag filled with morselized allograft in an interspace may be reported using 20930. Bone Marrow Aspiration CPT Description Code 38220 Bone marrow; aspiration only (For needle aspiration of bone marrow for the purpose of bone grafting, use 38220) May report 38220 when bone marrow aspirate is harvested via a separate skin or fascial incision (e.g., iliac crest). Do not report 38220 when bone marrow aspirate is harvested from the same surgical site (e.g., pedicle) Do not use a bone marrow transplant code such as 38230. 9

Laminectomy For Stenosis Codes Laminectomy for Stenosis / Spondylosis 63001 63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), one or two vertebral segments Cervical (63001), thoracic (63003), lumbar (63005) and sacral (63011) No additional level codes Primary diagnosis is stenosis May not report with modifier 50, procedure is inherently bilateral Example of 63001: Decompressive laminectomies at C2 and C3 for stenosis 63015 63017 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), more than 2 vertebral segments Cervical (63015), thoracic (63016) and lumbar (63017) No additional level codes Primary diagnosis is stenosis May not report with modifier 50, procedure is inherently bilateral Example of 63015: Decompressive laminectomies at C2, C3, C4 and C5 for stenosis 63045 +63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral) with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), single vertebral segment Cervical (63045), thoracic (63046) and lumbar (63047) +63048 is the add-on code for this family of codes May not report with modifier 50, code says unilateral or bilateral Primary diagnosis is usually stenosis or spondylosis Use for revision (re-do) laminectomy when performed due to stenosis do not report 63042. Report one code per interspace/level of foraminotomy Use code for minimally invasive procedure (e.g., using tubular retractor system). Report code(s) the same as if performed via longer incision. For example, a bilateral L4-L5 procedure via two small minimally invasive incisions is one code, 63047, and not two codes. Example of 63047: L4-5 partial laminectomies, foraminotomies and partial facetectomies for stenosis ALERT: CPT Assistant, December 2012 supports the use of 63045-63048 for procedures to address stenosis and the use of 63020-63035 for procedures to treat disc disease. 10

Laminectomy For Disc Disease Laminectomy for Disc Disease 63020 63030 +63035 ALERT: Repair of the annulus is included in the discectomy codes and not separately reported with an unlisted code such as 22899 or 64999 (CPT Assistant, December 2012). Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace. Cervical (63020) or lumbar (63030); no thoracic code +63035 is the add-on code for this family of codes May report with modifier 50, these are unilateral codes Primary diagnosis is disc disease Use code for minimally invasive procedure (e.g., using tubular retractor system). Report code(s) the same as if performed via longer incision. For example, excision of right L4-L5 and right L5-S1 discs via two small minimally invasive incisions is 63030 and +63035 (not 63030 and 63030). Do not use this series of codes for percutaneous discectomy where procedure is performed under fluoroscopy and there is no direct visualization of the anatomy look at 62287 instead. Endoscopically assisted laminotomy (hemilaminectomy) requires open and direct visualization. When visualization is only endoscopic and/or image guidance, the procedure is percutaneous and reported using 0274T, 0275T. So, be sure to document direct visualization! Includes annulus closure/repair using any sort of annulus closure device or soft tissue reinforcement do not separately report 22899. Example of 63030: Left L4-5 hemilaminectomies, foraminotomy and discectomy for herniated disc 63040 +63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace These codes are used for re-exploration discectomy procedures performed at the exact same level(s) as the previous procedure when the surgeon is out of the global period for the first procedure Cervical (63040) or lumbar (63042) no thoracic codes +63043 is the add-on code for a reexploration cervical level; +63044 is the add-on code for reexploration lumbar level May report with modifier 50, these are unilateral codes Codes are valued higher to account for additional work involved with performing a re-exploration (e.g., excision of scar tissue, distorted landmarks) Includes annulus closure/repair using any sort of annulus closure device or soft tissue reinforcement do not separately report 22899. Check your local Medicare carriers and private payors for their reimbursement policies on the additional level codes (63043 and 63044). Most Medicare carriers have an allowable even though the Federal Register designates this code as carrier priced with zero RVUs Example of 63042: Reexploration left L4-5 partial laminectomies, foraminotomy and partial facetectomy for disc disease 11

Other Laminectomy Codes Laminectomy for Spondylolisthesis (Gill Procedure) 63012 Laminectomy with removal of abnormal facets and/or pars interarticularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) May not report with modifier 50; no add-on code Procedure is almost always done at L5-S1 for a single interspace decompression Involves laminectomy and removal of both articular facets. Typically involves a pars defect (e.g., fracture, loose lamina). Diagnosis of spondylolisthesis not disc disease, stenosis or spondylosis Transpedicular Approach, Lumbar 63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (e.g., far lateral herniated intervertebral disc) +63057 is the add on code May not report bilaterally An approach to disc removal that typically includes removal of the pedicles and/or facet joints Diagnosis is typically far lateral herniated disc Not to be used for transforaminal lumbar interbody fusion (TLIF) approaches (22630) or percutaneous endoscopic discectomies (62287). Do not use 63056 just because you are doing a TLIF rather consider 63047 instead. Use 63055 for thoracic Percutaneous Laminotomy/Laminectomy 0274T 0275T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic lumbar Codes include fluoroscopy and CT imaging do not separately report 7xxxx codes Use 62287 for percutaneous decompression of the nucleus pulposus of intervertebral disc utilizing needle based technique Use 63020-63020 for open/direct visualization approach; do not use 63020-63020 if direct visualization is not performed and documented 12

Laminectomy Cases 1. Diagnosis: Lumbar stenosis Procedure: Right minimally invasive L4-L5 foraminotomy and hemilaminectomy for stenosis. 2. Diagnosis: Herniated disc Procedure: Left L2-L3 hemilaminectomy, facetectomy, discectomy and foraminotomy for with use of the operating microscope for microdissection. Repair of annulus and soft tissue reinforcement. A B 63030 L2-L3 discectomy 63030 L2-L3 discectomy 22899 Annulus repair +69990 Use of operating microscope +69990 Use of operating microscope 3. Diagnosis: L5-S1 herniated disc, L4-5 spinal stenosis Procedure: 1) Left L5-S1 hemilaminectomy, facetectomy and discectomy 2) Decompressive laminectomy with foraminotomies at L4-L5 A B 63047 Laminectomy, foraminotomy 63030 Discectomy 63030-59 Discectomy +63035 Additional level discectomy 4. Diagnosis: L4 and L5 stenosis Procedure: Partial L4 and L5 laminectomies and facetectomies with foraminotomy at L4-L5 for decompression of the L4 exiting nerve root and L5 traversing nerve root with use of the operating microscope for microdissection. A B 63047 Laminectomy, foraminotomy 63047 Laminectomy, foraminotomy +69990 Use of operating microscope +63048 Additional level, laminectomy +69990 Use of operating microscope 5. Diagnosis: L4-L5 herniated disc and stenosis Procedure: Left L4-L5 partial laminectomies, partial facetectomy and discectomy 6. Diagnosis: Stenosis Procedure: Decompressive L4-L5 laminectomies 13

Laminectomy Cases 7. Diagnosis: Lumbar stenosis Procedure: Partial inferior laminectomy L4 and complete laminectomy L5, facetectomies and L4-L5 and L5-S1 foraminotomies. 8. A. Re-do right L4-5 discectomy 6 weeks postop B. Re-do right L4-5 discectomy one year postop 9. Re-exploration laminectomies, foraminotomies, discectomies, right L4-L5 and right L5-S1 10. Re-exploration bilateral L4-5 hemilaminectomies, foraminotomies with partial facetectomies and discectomies. 11. Diagnosis: Right L4-L5 recurrent herniated disc, L3-L4 stenosis Procedure: Re-exploration laminectomies, foraminotomies and discectomy, right L4-L5 with decompressive L3-L4 laminectomy with facetectomies and foraminotomies 12. Re-exploration right laminectomy and foraminotomy at L4-5 for stenosis. A B 63047 Laminectomy, foraminotomy 63042 Re-exploration laminotomy (hemilaminectomy) 13. Diagnosis: Lumbar spinal stenosis Procedure: Minimally invasive with direct visualization right L2-L3 and right L4-L5 partial laminectomies and foraminotomies through 2 separate stab incisions. A B 63047 Laminectomy, foraminotomy 63047 Laminectomy, foraminotomy, first incision +63048 Additional level 63047-59 Laminectomy, foraminotomy, second incision 14

Posterior Fusions Cervical CPT Code Description 22590 Arthrodesis, posterior technique, craniocervical (occiput-c2) 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) Thoracic Lumbar 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment +22614 each additional segment (List separately in addition to code for primary procedure) There are no add-on codes for 22590 or 22595. If an arthrodesis is performed from the occiput to C3 then report 22590 and 22600. CPT Code Description 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) +22614 each additional segment (List separately in addition to code for primary procedure) CPT Code Description 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or lateral transverse technique, when performed) +22614 each additional segment (List separately in addition to code for primary procedure) 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar +22632 each additional interspace (List separately in addition to code for primary procedure) 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar +22634 each additional interspace and segment (List separately in addition to code for primary procedure) Coding Tips: Do not report 22612 in conjunction with 22630 for the same interspace and segment, use 22633. Use 22614 in conjunction with 22600, 22610, 22612, 22630 or 22633 when performed at a different level. Tip: Report one stand-alone fusion code even when the procedure crosses spine junctional levels. Use the stand-alone fusion code for the spine region where the majority of the procedure/ levels is performed. 15

Posterior Fusions Can a decompressive laminectomy (i.e., 63047) code be reported with 22630 or 22633? Medicare bundles 63047 when performed with 22630. CPT considers it an accurate coding combination, if decompression above that needed for the PLIF is performed and documented. CPT Assistant, January 2001 says (paraphrased) the appropriate 63045-63048 code(s) should be reported, when in addition to removing the disc and preparing the vertebral endplate, the surgeon removes posterior osteophytes and decompresses the spinal cord or nerve root(s), which requires work in excess of that normally performed when doing a posterior lumbar interbody fusion (PLIF). For example, in spinal procedures performed on patients having lateral lumbar stenosis, the surgeon may need to perform additional work above and beyond that described by the PLIF, including facetectomy(ies) and/or foraminotomy(ies), to adequately decompress the nerve roots. For the purpose of this example, code 63047 should be reported in addition to code 22630. APPEAL DENIALS OF 63047 WHEN BILLED WITH 22633 I am submitting an appeal for Ms. Patient s denied code 63047. As you will see on the attached claim, code 22633 is the primary procedure and code 63047 is a secondary procedure. According to the American Medical Association s Current Procedural Terminology (CPT) codebook and the American Association of Neurological Surgeons (AANS) guide, 63047 is considered separately reported when performed for decompression (please see attached copy of the CPT codebook page and the AANS guide page) in conjunction with 22633. In addition, review of Medicare CCI edits show a CCI edit exists with 22633 and 63047 and the suprascript of 1 means modifier 59 may be used to override this edit, if requirements for use of 59 are met. As you will see from the attached operative note, the highlighted areas reflect separately performed foraminotomies for decompression (63047) warranting use of modifier 59. As a result we respectfully request payment for 63047. If you have unique bundling edits in place for this code combination please send a hard copy to my attention. Thank you for your time and reconsideration. CPT Assistant, November 2011 22630 with 63056 Question: May both code 63056, Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disk), single segment; lumbar, and code 22630, Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar, be reported for the same interspace/segment? Answer: No. To report both codes 63056 and 22630 for the same interspace/segment would represent duplicative work. For posterior (PLIF) or transforaminal (TLIF) approach lumbar interbody fusions, CPT code 22630 is used, and the dissection needed to access the disc space in these approaches is considered an incidental component of the fusion procedure. Although code 22630 includes the phrase including.discectomy to prepare interspace (other than for decompression) and code 63056 is a discectomy for decompression, the discectomy described in code 22630 is either the same or more extensive than the discectomy described in code 63056. 16

Other Procedures Pre-Sacral Interbody Fusion Placement of Posterior Instrumentation? New in 2013! YES NO 22586 L5-S1 +0309T L4-L5 0195T L5-S1 +0196T L4-L5 22586 Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace (Do not report 22586 in conjunction with 20930-20938, 22840, 22848, 72275, 77002, 77003, 77011, 77012) +0309T Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure) (Use 0309T in conjunction with 22586) (Do not report 0309T in conjunction with 20930-20938, 22840, 22848, 72275, 77002, 77003, 77011, 77012) 0195T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace 0196T L4-L5 interspace (List separately in addition to code for primary procedure) (Do not report 0195T, 0196T in conjunction with 20930-20938, 22558, 22840, 22845, 22852, 72275, 76000, 76380, 76496, 76497, 77002, 77003, 77011, 77012) 17

Other Procedures Facet Wedge or Dowel Fusion (Intrafacet Implant) Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level Cervical: 0219T Thoracic: 0220T Lumbar: 0221T Additional level: +0222T Includes fluoroscopy and any radiological service Includes bone graft, instrumentation and fusion do not report 0219T-0221T with +20930, +20931, 22600-22614, +22840, +22851 at the same level. Posterior Spinous Process Distraction Device 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 (List separately in addition to code for primary procedure) Also called interspinous process implant May report with decompression code (e.g., 63047) Example: Intraspinous process fusion L5-S1, left L5 partial laminectomy Description of Procedure:..incision was made in the midline fascia was split midline over the spinous processes. attention was turned to the left side where partial laminectomy was performed. Next, the distraction device was placed over the spinous process and used to distract the L5-S1 joint and x-ray identified adequate distraction with a size 10 implant. Once this was confirmed, actual size 10 implant was put in place. X-ray confirmed placement of the intraspinous process device. Then plate was measured and size 4 to 5 was an adequate fit. It was placed between the spinous processes of L5-S1 without difficulty and excess midline bulk was cut and removed. X-ray fluoroscopy was then used to take final pictures and device was found to be in adequate location on both AP and lateral views. The wound was irrigated. Astramorph was injected into the dural space. The lumbar fascia was closed, skin and subcutaneous tissues were closed with sutures followed by Dermabond, 4x4s, Steri-strips and Tegaderm. 18

Other Procedures (continued from previous page) A B 22612 Posterior fusion, first level 0171T Insertion of posterior spinous process distraction device 22840 Non-segmental instrumentation 63030-RT Lumbar discectomy, first level 63035-LT Additional level 62311 Injection of Astramorph Posterior Spinous Process Fixation Device 22899 Unlisted procedure, spine Also called interspinous process clamp Example: Interlaminar lumbar fusion with spinous process fixation device May report with decompression code (e.g., 63047), arthrodesis (e.g., 22612) and/or bone graft (e.g., 20936) Do not use 22841 or 22840 Example Interlaminar lumbar instrumented fusion including distraction of space between the spinous processes, removal of small sections of bone to relieve pressure on the spinal cord and nerves, and placement of a precision-machined allograft bone between the spinous processes for permanent distraction and fixation. A small plate is then attached to both spinous processes to stabilize the segment and promote fusion A B 22612 Posterior fusion, first level 22612 Posterolateral fusion, first level 22841 Spinous process wiring 22899 Unlisted procedure, spine 20931 Structural allograft 20931 Structural allograft Percutaneous Sacroiliac Joint Stabilization 22899 Unlisted procedure, spine Minimally invasive S-I joint fusion performed percutaneously for degenerative disease Accepted Category II code 0301XT to report percutaneous stabilization of the sacroiliac joint (SIJ), but currently being appealed with request received by AMA to delay publication of this Category III code. Use 22899 (unlisted procedure, spine) until Category III code issue resolved 19

Posterior Fusion Cases Case #1 1. L4-5 posterolateral fusion with pedicle screws and rods, local bone 2. L4-5 laminectomies, foraminotomies and partial facetectomies to decompress the nerve roots Case #2 1. L5-S1 Laminectomy and discectomy 2. TLIF L5-S1 with PEEK device and BMP 3 L5-S1 pedicle screw and rod placement Case #3 1. L5-S1 partial laminectomies, facetectomies and foraminotomies for decompression of the nerve roots. 2. L5-S1 TLIF with placement of PEEK device and morselized allograft 3. L5-S1 posterior fusion with pedicle screws and rods and local bone. A B 22633 Combined posterior fusion and interbody fusion 22633 Combined posterior fusion and interbody fusion 63047-59 Decompression 63056-59 Transpedicular decompression +22840 Instrumentation +22840 Instrumentation +22851 PEEK device +22851 PEEK device +20930 Morselized allograft +20930 Morselized allograft +20936 Local bone +20936 Local bone Case #4 1. L5-S1 discectomy and TLIF with placement of PEEK cage and local autograft. 2. L5-S1 posterior fusion with pedicle screws and rods and local bone graft. 20

Exploration of Fusion and Hardware Removal/Reinsertion Codes CPT Guideline Codes 22849, 22850, 22852, and 22855 are subject to modifier 51 if reported with other definitive procedure(s), including arthrodesis, decompression, and exploration of fusion. Code 22849 should not be reported in conjunction with 22850, 22852, and 22855 at the same spinal levels. Only the appropriate insertion code (22840-22848) should be reported when previously placed spinal instrumentation is being removed or revised during the same session where new instrumentation is inserted at levels including all or part of the previously instrumented segments. Do not report the reinsertion (22849) or removal (22850, 22852, 22855) procedures in addition to the insertion of the new instrumentation (22840-22848). CPT Code Description 22830 Exploration of spinal fusion 22849 Reinsertion of spinal fixation device 22850 Removal of posterior nonsegmental instrumentation (e.g., Harrington rod) 22852 Removal of posterior segmental instrumentation 22855 Removal of anterior instrumentation ALERT There is no code for removal of an intervertebral device this would be part of an exploration of fusion. Do not use 20680 (removal of implant) for removing spine instrumentation. 21

Exploration of Fusion and Hardware Removal/Reinsertion Codes 1. Purpose of operation is to extend a solid fusion to an adjacent level. Example: Removal of C6-C7 plate to perform a C5-C6 ACDF. Recommendation: Do not report 22830 (exploration) for the solid fusion level. Do not report instrumentation removal code (e.g., 22850, 22852, 22855). Report the appropriate fusion code and the appropriate code for the length of the new instrumentation. Teaching Point: No exploration is needed for a solid fusion and given the significant overlap in physician work so code for the new instrumentation placed. Remember, CPT says not to report a removal code in addition to an insertion code. 2. Purpose of the operation is to explore a fusion because pseudoarthrosis is suspected - no extension of the fusion. Recommendation: Report 22830 (exploration) of the level with pseudoarthrosis (report code once per operation). Report re-insertion of instrumentation (because removal and replacement was at exact same level(s) 22849). Do not report a new instrumentation code (e.g., 22842). Report fusion code (e.g. 22612, 22554). 3. Purpose of operation is to explore a fusion because pseudoarthrosis is suspected - there WILL be extension of the fusion. Example: Removal of L5-S1 rods (and screws, when performed) with L4-L5 fusion and placement of pedicle screws at L4-L5 and new rods at L4-S1. Recommendation: Report 22830 (exploration) Report new instrumentation code for entire length of new construct (e.g., 22842) Report fusion code (e.g. 22612) Teaching Point: Do not code instrumentation removal (22850, 22852, 22855) unless it was at a non-adjacent level(s) due to the overlap in work. 22

Anterior Cervical Decompression/Fusion Anterior Cervical Arthrodesis/Fusion Anterior Cervical Decompression CPT Code Description 22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 +22585 each additional interspace (list separately in addition to code for primary procedure) CPT Code Description 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), inclduing osteophytectomy; cervical, single interspace +63076 each additional interspace (list separately in addition to code for primary procedure) When performed together at the same level(s), report: Anterior Cervical Discectomy/Decompression and Fusion CPT Code Description 22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophyectomy and decompression of spinal cord and/or nerve roots; cervical below C2. +22552 cervical below C2, each additional interspace (list separately in addition to code for separate procedure) Tips: Do not bill 22554 in conjunction with 63075, even if performed by a separate individual. Codes 22551 and 22552 include 69990 (do not separately report 69990 with 22551 or 22552). CPT 63075 also includes 69990. Use 22554 when performed with codes other than 63075 (e.g., 63081 corpectomy). Use 63075 when performed with code other than 22554. 23

ACDF Cases Anterior Cervical Discectomy/Decompression and Fusion Examples Number of Levels One (e.g., C5-C6) Two (e.g., C5-C6, C6-C7) Three (e.g., C4-C5, C5-C6, C6-C7) With Structural Allograft and Anterior Plate 22551 (ACDF) +22845 (Plate) +20931 (Allograft) 22551 +22552 (Add. Level) +22845 +20931 22551 +22552 +22552-59 +22846 +20931 OR 22551 +22552 x 2 units +22846 +20931 With PEEK Device, Separate Anterior Plate, and Morselized Allograft 22551 +22845 +22851 (PEEK device) +20930 (Allograft) 22551 +22552 +22845 +22851 +22851-59 +20930 OR 22551 +22552 +22845 +22851 x 2 units +20930 22551 +22552 +22552-59 +22846 +22851 +22851-59 +22851-59 +20930 OR 22551 +22552 x 2 units +22846 +22851 x 3 units +20930 With Combined PEEK Device/Screws/Plate and Morselized Allograft 22551 +22851 +20930 22551 +22552 +22851 +22851-59 +20930 OR 22551 +22552 +22851 x 2 units +20930 22551 +22552 +22552-59 +22851 +22851-59 +22851-59 +20930 OR 22551 +22552 x 2 units +22851 x 3 units +20930 Note: May substitute/add other bone graft(s) as appropriate (e.g., +20936, +20938) 24

ACDF Case 1. Non-adjacent two level fusion (e.g., C4-C5 and C6-C7) anterior cervical discectomies and fusion with PEEK intervertebral devices, placement of morselized allograft in the PEEK device, and two separate anterior plates that are placed at C4-C5 as well as at C6-C7. A 22551 ACDF 22551 ACDF 22551-59 ACDF, second level +22552 Additional level +22845 Anterior instrumentation +22845 Anterior instrumentation +22845-59 Anterior instrumentation +22845-59 Anterior instrumentation +22851 Intervertebral device +22851 Intervertebral device +22851-59 Intervertebral device +22851-59 Intervertebral device +20930 Morselized allograft +20930 Morselized allograft 2. Procedure: 1) C4-C5 anterior cervical discectomy/decompression of spinal cord and nerves 2) Arthrodesis with placement of PEEK intervertebral device, plate with allograft and autograft Surgeon: Dr. Unbundler Co-Surgeon: Dr. Partner A 63081-62 59 Partial corpectomy, first level 22551 ACDF +63082-62 Partial corpectomy, second level +22845 Anterior instrumentation 63075-62, 59 Anterior cervical discectomy +22851 Intervertebral device +22845-62 Anterior instrumentation +20930 Morselized allograft +22851-62-59 Intervertebral device +20936 Morselized autograft 22554-62, 59 Anterior cervical fusion 22808-62 Anterior cervical fusion 22551-62, 59 ACDF 64714-62 Neuroplasty 64714-50, 62 Neuroplasty 22220-62 Osteotomy, cervical +22226-62 Additional level osteotomy 22326-62 Cervical fracture repair +20930-62 Morselized allograft +20936-62 Morselized autograft 76001-62 Fluoroscopy 77002-62 Fluoroscopy 95920-26 Intraoperative monitoring 95937-62 Neuromuscular junction test +69990-62 Use of operating microscope 95937-62 Neuromuscular junction test B B 25

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