Jeffrey B. Neustadt, MD
Coding Committee Chair
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, Chairman, Coding Committee
Growing rod surgery does not have specific or accurate CPT codes assigned. The initial surgery includes segmental instrumentation, limited fusions, as well as bone grafts. Lengthening surgery may or may not include a revision to the instrumentation. The conversion of a growing rod construct to a final posterior spine fusion with instrumentation involves removal of segmental instrumentation, more fusion, insertion of different instrumentation, bone grafts, and possibly Ponte or Smith-Petersen osteotomies. With this potpourri of procedures, accurate CPT coding becomes challenging. Therefore the Coding Committee felt a discussion of this topic would be of interest given the growing incidence of this type of spinal deformity surgery.
The following scenario will illustrate the use of CPT codes which may be considered appropriate for use in growing rod-related surgical procedures:
An ambulatory, five year old girl with syndromic scoliosis which has progressed to 90 degrees and includes significant pelvic obliquity undergoes growing rod instrumentation from T4 to the pelvis. Pedicle screws are placed bilaterally at T4 and T5 as well as at L5 and S1 along with bilateral iliac screws. Iliac bolt connectors are used to connect the iliac screws to two rods (actually four rods: two on each side connected by growing rod connectors) extending from T4 to the sacrum. Local bone and allograft demineralized bone matrix soaked in bone marrow aspirate is used as bone graft to fuse T4 to T5 and L5 to S1. The following CPT codes would be appropriate:
Note that 22844 and 22848 are Modifier 51 Exempt. 38220 is NOT modifier 51 Exempt.
Coding experts advise use of the following codes as well, although they have no relative value units assigned and therefore do not result in additional reimbursement:
Six months later, the child undergoes a lengthening of the growing rod instrumentation. There is no accurate CPT code for this procedure. Two possible codes may be considered:
While the latter code may seem more appropriate, it is problematic for most insurance companies as it requires a detailed explanation for why it is being used and still may be denied.
Six years later, the child undergoes a conversion to a full posterior spine fusion with instrumentation. Her growing rods are removed; the iliac screws and the screws at T4, T5, L5, and S1 are converted to larger screws which will accommodate 5.5 mm rods rather than 4.5 mm rods; more screws are placed at multiple segments from T5 to L4; 5 Ponte osteotomies are performed from T10 to L3 to improve correction of the significant thoracic hypokyphosis, and two Smith-Petersen osteotomies are performed at T6 and T7 where autofusion occurred over the years; a fusion from T5 to L5 is performed using local bone graft, allograft, and bone marrow aspirate. The following CPT codes would be utilized:
Note that although the segmental instrumentation spans more than 12 levels or segments, the fusion only spans 12 because the patient already underwent fusion of T4 to T5 and L5 to S1, leaving only T5 to L5 to be fused. Therefore CPT code 22802 is utilized rather than 22804 which would be for arthrodesis of 13 or more vertebral segments.
Also note that if no new levels were instrumented and the surgeon merely replaced the original screws with ones accommodating larger rods, one would not use 22844 and 22848 but instead would use 22849 - reinsertion of spinal fixation device.
Codes 22852, 22214, 22216, 22849 and 38220 are not Modifier 51 Exempt, while codes 222802 (the primary code here because it has the highest number of RVU's assigned), 22844, and 22848 are Modifier 51 Exempt.
Correct coding is important both for correct reimbursement as well as correct documentation of surgical procedures performed. As one can see with the scenario of growing rod instrumentation, it is not always possible to find codes which accurately reflect what was done. In such situations, consultation with coding experts may be helpful. Appeals of denied codes may also be necessary. As always, accurate dictated documentation of performed procedures is mandatory.
Chairman: Jeffrey Neustadt, MD Committee Members: Barton L. Sachs, MD; David B. Cohen, MD; Brandon J. Kambach, MD; R. Dale Blasier, MD; Christopher DeWald, MD; Michael P. Chapman, MD.