Spine Procedures and Coding

Spine Procedures: A Reenactment and Coding Guide

Patient Presentation

  • Patient complains of neck pain radiating down the arm.
  • Referred to a neurosurgeon.
  • Diagnosis: Cervical disc herniation with osteophytes at the C5 and C6 levels.

Understanding the Spinal Anatomy

  • Spinal Cord: The yellow image represents the spinal cord.
  • Disc: The inflamed disc (red) is located between the C5 and C6 vertebrae.
  • Disc Bulge: The disc is bulging out and touching the spinal cord.
  • Bone Spurs: Also known as osteophytes, located underneath the herniation.
  • Cervical Disc Herniation: Herniation occurs in the cervical spine between C5 and C6.

Surgical Recommendation

  • The patient is recommended for surgery.
  • Scheduled procedure: Cervical discectomy and osteophytectomy at the C5-C6 level.

Surgical Procedure Step-by-Step

1. Patient Positioning and Approach
  • Patient is prepped and draped in a sterile fashion.
  • Position: Supine.
  • Approach: Anterior (incision made from the front).
  • Supine position is an indicator of an anterior approach.
2. Visualization
  • Retractors are placed to hold the skin back.
  • This allows the surgeon to visualize the surgical site properly.
3. Definitive Procedures: Discectomy and Osteophytectomy
  • Discectomy: Removal of the disc from between C5 and C6 using a ronguer.
  • Osteophytectomy: Removal of bone spurs using a burr.
4. Graft Harvesting
  • Bone graft is needed to fill the hollow space left by the discectomy.
  • Harvesting: Obtaining the bone graft.
  • Source: Iliac crest (the large part of the hip), a common source of graft material, is harvested.
  • Process: Bone is harvested from the iliac crest, mixed with the patient's blood in a grinder to achieve the right consistency.
5. Graft Implantation (Fusion/Arthrodesis)
  • Graft is placed between C5 and C6 in the hollow space.
  • This process is called fusion or arthrodesis.
6. Instrumentation
  • Instrumentation is applied to secure the graft in place.
  • Type: Non-segmental instrumentation (only one piece to the instrumentation).
7. Closure and Follow-Up
  • Surgeon removes all surgical instruments.
  • The patient is sutured up carefully.
  • Follow-up: The patient returns after six weeks for a follow-up visit where the surgical site is evaluated, and the patient may be released from care.

Coding Spine Procedures: Summary

  • Coding involves several components; however, not all are present in every surgery.
  • Key Steps:
    • Code the approach (anterior, posterior, or lateral).
    • Code the definitive procedures (discectomy, osteophytectomy).
    • Code the harvesting of the bone graft implant.
    • Code the fusion or arthrodesis.
    • Code the spinal instrumentation.
  • Osteophytectomy is often a bundled procedure, requiring only one code.

Forensic Reading: Key to Success

  • Understand what procedures are being performed and only code for those procedures.

Spine Procedures: FTRs (Follow The Rules)

1. Approach
  • The way the doctor approaches the procedure.
  • Determined by patient position: supine (anterior), prone (posterior), or lateral (lying on the side).
2. Number of Discs/Segments
  • Know the number of discs and/or segments being coded for.
3. Definitive Procedure
  • Determine if a definitive procedure is being carried out and which one.
4. Arthrodesis
  • If arthrodesis is performed with other definitive procedures, append modifier 51 to the arthrodesis procedure.
5. Instrumentation and Bone Graft
  • Note whether instrumentation and bone graft were used.

General Keywords

  • Arthrodesis, instrumentation, decompression, discectomy, osteotomy/osteophyte removal, laminectomy.

Coding Quirks and Guidelines

  • Read the guidelines to eliminate quirks.
  • Forensic reading is essential.
  • Code instructions may specify coding the first segment separately and then subsequent codes.
  • Add-on codes: Do not append modifier 51.
  • Instrumentation and bone grafts are often add-on codes.

Definitive Procedures: FYIs (For Your Information)

1. Modifier 51
  • Append modifier 51 for subsequent definitive procedures (only one primary procedure can be coded without a modifier).
2. Co-Surgeons
  • Many spine procedures involve co-surgeons.
3. Parenthetical Guidelines
  • Watch the parenthetical guidelines; they provide essential guidance.
4. Bundled Procedures
  • Be aware of bundled procedures (e.g., osteophytectomy bundled with discectomy).
5. Nervous System Codes
  • Discectomy involves the spinal cord, so codes may come from the nervous system section.
  • Decompression relieves pressure on the spinal cord.
6. Musculoskeletal Section
  • Common definitive procedures (bone incisions and excisions) may come from the musculoskeletal section.
  • Examples: laminectomy, osteotomy, foraminotomy, corpectomy, spinal cord decompression.

Revised FTRs for Definitive Procedures

  • Approach
  • Definitive procedure
  • Arthrodesis (append modifier 51)
  • Instrumentation
  • Bone grafting
  • Number of discs/segments

Excision Section: Code 2210

  • Pay attention to code language detailing the specific part of the spine and the number of segments involved.
  • Read parenthetical guidelines for additional instructions.

FTRs for Arthrodesis/Fusion: Code Series 22532 through 22819

1. Approach
  • Note the approach used.
2. Instrumentation
  • Determine if instrumentation was used.
3. Number of Spaces/Levels
  • The number of spaces determines the number of levels.
4. Co-Surgeons
  • Use modifier 62 for co-surgeons.
  • Arthrodesis immobilizes the joints using grafting material and/or instrumentation.

Instrumentation - Code series 2284 through 22859

  • Most of these procedures are add-on codes
  • If you are coding instrumentation for spine surgery, you must code arthrodesis.
1. Type of Instrumentation
  • Determine the type of instrumentation.
  • Segmental: Attachments are at the end of the repair area, and at least one other attachment is in the area being repaired.
  • Non-segmental: Attachment of the devices is at the ends of the area being repaired.
2. Modifier 51 for Reinsertion, Removals, or Explorations
  • Report modifier 51 for reinsertion, removals, or explorations.
3. Approach
  • Codes are classified according to the approach.
4. Instrumentation: FTRs
  • Spine surgery must be coded with arthrodesis.
  • Segmental or non-segmental approach.
  • Report modifier 51 for reinsertion, removal, or exploration.

Bone Graft/Implant FTRs: Code Series 20900 through 20939

  • Bone grafts can be coded for any surgery, so these guidelines are general (except FTR number two).
1. Separate Coding
  • Code separately unless bundled in the code language.
2. Arthrodesis
  • Spine surgery must be coded with arthrodesis or fusion.
3. Modifier Guidelines
  • Do not report bone grafts with modifier 62.
  • Do not report bone graft add-on codes with modifier 51.

Coding Exercise

  • Scenario: Posterior arthrodesis of L4 through S1 utilizing morselized allogenous iliac bone graft with pedicle screw fixation.
  • Plan: Arthrodesis, instrumentation, then bone graft.
Keywords:
  • Posterior arthrodesis of L4 through S1
  • Morselized allogenous bone graft
  • Pedicle screw fixation

FTR : Arthrodesis Procedures

Number of spaces determines the number of levels:

  • Solution: C) 22612, 22614, 22842, 2093
  • Explanation:
    • Arthrodesis: Count the spaces between L4 and S1 (two spaces).
      • 22612: Arthrodesis, posterior, below C2; lumbar
      • 22614: Code for each additional vertebral segment (add-on code;exempt from 51 modifier)
    • Parent Medical Guideline:
      • Use 22614 in conjunction with 600, 610, 612, 630, or 633 when performed at a different level.
    • Instrumentation: Posterior segmental instrumentation (pedicle screw fixation).
      • 22842: Posterior segmental instrumentation such as pedicle fixation.
    • Bone Graft: Allograft for spine surgery.
      • 2093: Allofraft for spine surgery