CPT Coding for Spine Surgery Series

Introduction to Spine Surgery CPT Coding

• Course updated with new content indicated by an asterisk (*).
• Course focuses on CPT coding for spine surgery.
• Spine surgery coding is complex, requires understanding of the four main components.
• Course 1 covers arthrodesis and grafting codes.
• Grafting is essential for spinal fusion coding.
• Reviews different surgical approaches.
• Explores vertebral anatomy and level counting.
• Other courses cover decompression, corpectomy, instrumentation, and spinal deformity correction.
• Course includes five lessons and a scored assessment called the Code Red Ultimate Challenge.
• Lesson 1 covers anatomy, spinal disorders, and grafting codes.
  • Objectives: Describe arthrodesis, name the four components of spine surgery coding, and apply grafting codes.

Arthrodesis

• Arthrodesis: Literally means to bind a joint; focuses on its application to the spine.
• Spinal Fusion: Permanently connects two or more vertebrae, eliminating motion between them.
• Procedure: Bone or bone-like material is placed between vertebrae.
  • Metal plates, screws, and rods may be used for stabilization.

Common Reasons for Spinal Fusion

• Spinal Weakness / Instability: Abnormal motion between vertebrae due to arthritis.
  • Spinal fusion restores stability.
• Spinal Stenosis: Narrowing of bony openings within the spine, reducing space for nerves.
  • Causes pain, numbness, tingling, and muscle weakness.
  • treated by decompressing the nerve root and/or disc space, followed by fusion.
• Herniated Disc: Spinal fusion stabilizes the spine after disc removal.
• Spine Deformities: Corrects deformities like scoliosis.

Components of Spine Fusion Surgery

• A single spine surgery can include multiple separately reportable components.
• Capture all applicable CPT codes by reviewing clinical documentation.
• Components may be performed at one or more vertebral levels.
• This course focuses on the arthrodesis component.
• It is incorrect to only assign arthrodesis codes in a spine fusion surgery.

Grafting Procedures

• Graft material placed between vertebrae fuses the spine.
• Instrumentation (rods, screws) stabilizes the spine until fusion is complete.
• All graft codes are add-on codes and require a primary procedure code.

Types of Grafts

• Allograft: Acts as a bridge for natural bone growth.
  • Natural bone replaces the donor bone over time.
• Autograft: Bone taken from the patient's own body.
  • Differentiated by harvest location.
  • May be harvested through the same incision as the fusion or a separate incision.
  • Bits of bone removed from the vertebra in preparation for fusion are commonly used.

Coding Considerations for Grafting

• Multiple graft types (allograft combined with autograft) can be used.
• Each graft code is reported once, regardless of the number of levels.
• Bone Marrow Aspirate: Reported with CPT code 20939, obtained through a separate incision.
  • Sites: Sternum, tibia, or iliac crest.
  • Adding bone marrow aspiration to allograft improves fusion rates.

Lesson 2: Vertebral Anatomy and Counting Levels

• The adult spine consists of approximately 24 vertebrae: 7 cervical, 12 thoracic, 5 lumbar.
• Vertebrae protect the spinal cord and nerves contribute to body structure, and enable movement.

Vertebral Anatomy

• Spinous Process: Bony projection at the posterior of each vertebra for muscle and ligament attachment.
• Lamina: Arched part of the vertebral arch forming the roof of the spinal canal.

Counting Vertebral Levels in Spinal Fusion

• CPT Arthrodesis codes use "interspace" and "vertebral segment".
• Focus on anatomy to avoid confusion.
• Fusing a single level involves two vertebrae and one interspace (e.g., L4-L5 is one level).
• Fusion from L3 to L5 includes three vertebrae but two interspaces, so it's two fusion levels.

Lateral Extracavitary Approach

• CPT organizes arthrodesis codes by approach technique.
• Become familiar with patient positioning and anatomy.
• Lateral extracavitary approach is listed first in the arthrodesis series.
• CPT codes available: 22532, 22533, 22534.
  • Not applicable to the cervical spine; strictly for thoracic and lumbar.
  • Use primary code 22532 or 22533 based on fusion start location, then add-on code 22534 for each additional level.
• Involves accessing thoracic and lumbar vertebrae from the side.
• Allows better visualization of the anterior dural surface.
• Enables approach to lateral and anterior spine disease and posterior stabilization through the same incision.
• Documentation includes removal of parts of rib, transverse process, lateral parts of the facet, and pedicle.
• Goal: Gain access to the spinal cord, spinal canal, and disc space.

Anterior Approaches to Arthrodesis

• CPT code 22548: Arthrodesis, Anterior Transoral or Extraoral Technique, specific to C1-C2 vertebrae (atlantoaxial joint).
  • Allows head and neck movement.
  • Patient supine; incision may be in the back of the throat or outside of the neck.
  • Care taken to avoid the esophagus, pharynx, and esophageal nerve.
  • Retractors separate intravertebral muscles.
  • The odontoid process (dens) may be excised.
• CPT codes 22551 and 22552: Anterior approach to the cervical spine below C2.
  • Involves interbody spine fusion, placement of bone graft or device between vertebral bodies.
  • Patient is supine, incision through the neck; operative documentation includes description of discectomy and osteophytectomy for decompression.
  • Implant can be a structural graft or synthetic cage.
• CPT Codes 22554, 22556, 22558, and 22585:
  • Code 22554 is similar to 22551, but 22551 includes decompression and complete discectomy
    • CPT code 22551 was created in 2011 to describe anterior cervical discectomy and fusion.
    • CPT 22554 still exists for use when a decompression discectomy and arthrodesis are performed at different levels.
  • 22556 and 22558 for thoracic and lumbar spine, with add-on code 22585 for additional levels.
  • ALIF (Arthrodesis Anterior Interbody Technique) common for lumbar spine.

CPT 22586

It is a lumbar arthrodesis performed on the L5 S1 interspace using a presacral interbody technique.

• This technique uses a minimally invasive percutaneous approach to the anterior portion of the disc space. The technique is also known as transsacral.
• The patient is in a prone position with a small incision made at the level of the coccyx.

Posterior Approaches to Arthrodesis

CPT Codes 22590 and 22595

• 22595 is specific to C1 and C2.
  • Vertebral levels were discussed in the anterior approach.
  • This code represents a posterior approach instead of an anterior approach.
• 22590: Fusion from occiput to C2. Patient positioned prone with a head frame.

CPT Codes 22600, 22610, and 22612

• For vertebral levels lower than C2.
  • Code description: posterior or posterolateral, and can be used if either technique is used or both in the same session.
  • When a posterior fusion is done, the bone graft is placed on the backside of the vertebrae.
  • When a posterolateral is done, the graft to form the bony bridge can be placed next to the vertebrae.
  • Also includes lateral transverse fusion technique when performed.
    • Lateral transverse means the graft can be placed between transverse processes.
      *Patient is prone, incision down the back, paraspinal muscles elevated.

CPT22614

• Is an add-on code to be used with the 22600, 22610, 22612, 22630, 22633 codes when preformed at different interspaces.

Posterior Interbody Technique

• Primary code: 22630, add-on code: 22632 for additional levels (PLIF).
• Interbody technique: Fusion is placed in-between vertebral bodies where the disc usually lies. The device is a synthetic cage.
  * Discectomy or laminectomy preformed to prepare the interspace for fusion
  *Codes are only for the lumbar region.
  *Patient is prone and incision is preformed down the back where the paraspinal muscles are elevated.

CPT 22633 and 22634

Are a combination procedure on the lumbar spine.

• Involves performing interbody fusion and a posterior fusion at the same time.
• The report will indicate the placement of the interbody graft, posterior spinal element and additional grafting.
• The patient approach is posterior, and the patient is placed prone.

Add-on Codes and Multiple Spinal Fusions

• Add-on codes cannot be reported without a primary procedure.
• Identified by a plus sign (+) in front of the CPT code.
• Used to report additional interspaces in spinal fusions.

Coding Guidelines

• CMS has a database indicating approved primary procedures for add-on codes.
  • Claims will be rejected if an add-on code is reported without an approved primary code.
  • Payers may have different guidelines than CMS.
• CPT parenthetical notes provide reporting instructions.
  • Example: CPT 22614 (add-on code for posterior/posterolateral fusion).
  • Instructions specify to report with 22600, 22610, 22612, 22630, or 22633 when performed at a different interspace.

Reporting Spinal Fusions

1. Report multiple procedures separate skin incisions at different vertebral levels that are not next to each other and in different regions using one code per non-continuous region.
2. Report arthrodesis across multiple contiguous interspaces using the same incision but different techniques utilizing one primary code and an add-on code.