SRS Newsletter
March 2011
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UPDATE ON CODING FOR CORRECTION OF SPINAL DEFORMITY

By Jeffrey Neustadt, MD and R. Dale Blasier, MD
Chair and Chair-Elect of the Coding Committee

The Coding Committee has been asked to provide the membership with advice and examples to help understand the complexity of coding and reimbursement issues specific to spine and spinal deformity surgeons. Every effort has been made to be accurate and adhere to the ICD-9 coding conventions and guidelines as well as the CPT rules. However there may be unintended discrepancies or differences of opinion. With that in mind, these articles are not intended to provide legal advice to surgeons and their staffs. The information given by the committee should not be relied upon as an official interpretation of the AMA CPT® code book. The American Medical Association (AMA) is the only entity which can give an official and binding interpretation of the AMA CPT® code book, and should be contacted directly if an official comment is needed or desired. For more information contact the AMA CPT® Network at www.cptnetwork.com. It is our every intention that the articles we prepare for this year’s newsletters are helpful and useful to all members of the SRS and their staffs. - Jeffrey B. Neustadt, MD, Chair, Coding Committee

Correct procedural coding for correction of spinal deformity involves several unique issues. The common relevant issues include appropriate use of fusion levels, base codes, add-ons and modifiers. This article discusses several deformity correction scenarios and provides specific examples for their accurate coding.

Space does not allow for inclusion of all deformity correction coding issues, for example, video-assisted thorascopic surgery, vertical expandable prosthetic titanium rib, growing rods, anterior growth tethering surgery, kyphectomy, kyphoplasty, vertebroplasty and vertebral resection. These will be covered in future newsletters.

Determining Fusion Levels
In coding deformity correction, the number of segments involved in the surgery must be determined. The number of levels (2 segments = 1 level; total levels = total segments-1) determines the codes which will be used for the arthrodesis. The instrumentation code is based on the number of segments spanned. Typically these are the same but they may not be in some cases, e.g. posterior spinal fusion with instrumentation from T4 to L4. This would be coded as fusing 12 levels but instrumenting 13 segments. More on this later!

Base Codes and Add-Ons
All deformity corrections are described by one or more codes. Every surgical episode must have a base code, i.e. a code which can stand on its own. For spine, these include the codes for arthrodesis, osteotomy, hardware removal and reinsertion. Several common procedures such as instrumentation, bone grafting, insertion of cages, fixation to the pelvis and thoracoplasty are add-on codes which can never be reported by themselves. These must be reported in addition a base code.

Modifiers
Base codes are generally billed without modifiers and are expected to be reimbursed by payers at 100% of the usual rate. The preop evaluation, postop care and subsequent patient visits are presumed to be reimbursed by the base code. Add-on codes are valued based upon intraoperative work only and do not include reimbursement for preop evaluation or postop care. For this reason, they do not need multiple procedure modifiers and are not discounted by payers.

If multiple base codes are performed during the same procedure, the largest base code is generally billed first and is not discounted by the payer. Lesser base codes are billed subsequently and are appended by the 51 modifier. Because these codes are valued to include pre– and postop care which is redundant with the primary base code, the 51 modifier enables the payer to discount these codes to prevent multiple reimbursements for perioperative care. When using the osteotomy codes at multiple levels, some payers require the use of modifier 59 (distinct procedural service) to indicate additional separate levels and other payers require modifier 76 (repeat procedure by same physician).

Base Codes: Descriptions
Procedures which can be done by themselves and are valued to include pre– and postoperative work are indicated with base codes. These include arthrodesis (fusion), osteotomy and hardware removal or reinsertion:

  • Arthrodesis Codes

    Posterior:
    • 22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments (levels)
    • 22802 Arthrodesis, same; 7 to 12 vertebral segments (levels)
    • 22804 Arthrodesis, same; 13 or more vertebral segments (levels)
    Anterior:
    • 22806 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments (levels)
    • 22808 Arthrodesis, anterior, same; 4 to 7 vertebral segments (levels)
    • 22812 Arthrodesis, anterior, same; 8 or more vertebral segments (levels)
  • Osteotomy Codes

    • 22206 Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); thoracic
    • 22207 Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); lumbar
    Posterior column:
    • 22212 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; thoracic
    • 22214 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; lumbar
  • Hardware Manipulation

    • 22849 Reinsertion of spinal fixation device
    • 22250 Removal of posterior nonsegmental instrumentation (eg, Harrington rod)
    • 22852 Removal of posterior segmental instrumentation
    • 22855 Removal of anterior instrumentation

Add-on Codes: Descriptions
Add-on services (those with a ZZZ global period) contemplate services which are only intraoperative service. No pre– or postop care is included. These always must be billed in addition to a base code. Note that instrumentation can never be billed alone. It must always be performed in association with a base code which complicates coding for growing rod procedures.

  • Instrumentation Codes:

    Anterior:
    • 22845 Anterior instrumentation; 2 to 3 vertebral segments
    • 22846 Anterior instrumentation; 4 to 7 vertebral segments
    • 22847 Anterior instrumentation; 8 or more vertebral segments
    Posterior:
    • 22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation)
    • 22841 Internal spinal fixation by wiring of spinous processes
    • 22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments
    • 22843 same; 7 to 12 vertebral segments
    • 22844 same; 13 or more vertebral segments
  • Add-on Osteotomy:

    Three-column:
      22208 Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment
    Posterior column:
    • 22216 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; each additional vertebral segment
  • Bone Grafting
    Bone graft codes represent the harvest of the graft only. Reimbursement for implantation of the graft is included in the arthrodesis code. Note that 20930 and 20936 describe procedures that have been assigned a zero RVU value. 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only. Note that this code descriptor has been modified for 2011 to include "osteopromotive material".

    • 20931 Allograft for spine surgery only; structural
    • 20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision
    • 20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision)
    • 20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision)
  • Instrumentation to Pelvis

    • 22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum
  • Thoracoplasty

    No code describes this procedure well. The following have been reported with success:

    • 32905 Thoracoplasty, Schede type or extrapleural (all stages)
    • 22899 Unlisted procedure, spine
  • Insertion of cages

    Note that insertion of machined allograft is specifically not listed in this code descriptor:
    • 22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage[s], methylmethacrylate) to vertebral defect or interspace. Note that this code descriptor has been modified for 2011 to eliminate "threaded bone dowel[s]".

Other Adjunctive Procedures
Generally, supervision and interpretation of imaging for spine surgery—even for insertion of pedicle screws—is considered part of the procedure and should not be billed separately. Preparation and insertion of centrifuged blood products for deformity surgery is not reimbursable.

Examples of Surgical Coding

Scenario 1: Posterior Spinal Fusion for Kyphosis
This scenario describes a patient with kyphosis with an apex at T9. Instrumentation and fusion are performed from T2 to L2 (13 vertebrae, 12 segments or levels). Ponte or Smith-Petersen osteotomies are performed at T8–9, T9–10 and T10–11. Fragments excised at osteotomy are added to the fusion mass as bone graft. Additional graft is taken through a separate incision from the iliac crest.

For this procedure, the base code is: 22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments. The osteotomies could also be base codes because they are 90-day global codes, but the arthrodesis code has a higher RVU value.

The first osteotomy should be billed as: 22212 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; thoracic and should be appended with a 51 modifier because it is a 90-day global code.

The second and third osteotomies should be billed as: 22216 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; each additional vertebral segment. This is an add-on code and does not require a modifier.

The instrumentation should be billed as: 22844 Posterior segmental instrumentation; 13 or more vertebral segments. This is an add-on code and does not require a modifier.

The iliac bone graft should be billed as: 20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision). This is an add-on code which does not require a modifier. Note that bone graft codes assign value to the harvest and not the implantation.

The bone graft taken as fragments from the osteotomy should be billed as: 20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision. While this is billable, no work value is assigned to this code.

Scenario 2: Anterior Spinal Fusion for Scoliosis:
This scenario describes a patient with scoliosis with an apex at L1. The spine is approached by a right thoracolumbotomy. Instrumentation and fusion are performed from T11 to L3 (five vertebrae, four segments or levels). Fragments of the eleventh rib excised at thoracotomy are placed in the intervertebral spaces as bone graft. Cages are placed at the two lowest intervertebral spaces to maintain lumbar lordosis. During closure, a chest tube is placed.

The base code is:
22808 Arthrodesis, anterior, for spinal deformity, with or without cast; four to seven vertebral segments. The surgical approach is not separately billable. If another surgeon makes the approach for the spine surgeon, then spine and approach surgeon become co-surgeons for the base code which is appended by modifier 62. The base code includes preparing the disc spaces and insertion of bone graft.

The instrumentation code is:
22846 Anterior instrumentation; 4 to 7 vertebral segments) and includes any rod rotation, compression or distraction used to correct the deformity. No modifier is needed as this is an add-on code.

The bone graft is billed as:
20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision No modifier is needed as this is an add-on code. Note that the code has zero value.

The insertion of cages is billed as two episodes of:
22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace. No modifier is needed as this is an add-on code. The insertion, maintenance, and removal of the chest tube are included in the approach and are not separately billable.

Scenario 3: Posterior Spinal Fusion for Neuromuscular Scoliosis
This scenario describes a patient with a collapsing scoliosis of the whole spine. Instrumentation and fusion are performed from T2 to the sacrum (17 vertebrae, 16 segments or levels). Multiple pedicle screws, hooks and sublaminar wires are placed to secure the rods. Instrumentation stops at the sacrum and does not extend to the iliac wings. The iliac wings are small, osteoporotic and not considered a good source of graft, so allograft and a centrifuged blood product are placed to encourage fusion after the facet joints are excised.

The base code is: 22804 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments.

The instrumentation code is:
22844 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments).

If the instrumentation had extended to the ilia, it would have been appropriate to add: 22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum.

Placement of allograft is described by:
20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only

Placement of a centrifuged blood product is not covered by any code.