CPT Coding for Spine Part 3: Instrumentation and Devices

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CPT Coding for Spine Part 3: Instrumentation and Devices

• Focuses on instrumentation and devices, not spinal procedures (covered in other courses).
• Includes four lessons and a course assessment.

Lesson 1: Guidelines for Instrumentation

• Objectives:
  • Understand the purpose of instrumentation.
  • Define terms associated with instrumentation.
  • Differentiate between instrumentation and fusion.

Purpose of Instrumentation

• Instrumentation codes are add-on codes; they must be reported with a primary procedure.
• Instrumentation provides support and stability to the spinal column after procedures like fusion, decompression, or fracture treatment.
• Hardware acts as an internal brace to stabilize bony components during healing.
• Instrumentation does not cause fusion; fusion is achieved by the grafting material.

Definitions

• Vertebral Segment: A single complete vertebral bone with its articular processes and laminae.
• Vertebral Interspace: The non-bony compartment between two adjacent vertebral bodies, containing the intervertebral disc, nucleus pulposus, annulus fibrosis, and cartilaginous end plates.

Segmental vs. Non-Segmental Instrumentation

• Segmental Instrumentation: Fixation at each end of the construct and at least one additional interposed bony attachment.
• Non-Segmental Instrumentation: Fixation at each end of the construct, possibly spanning several vertebral segments without attachment to the intervening segments.

CPT Guidelines

• Spinal surgeries may require multiple CPT codes to reflect the combination of procedures.
• Various codes allow for reporting specific interventions performed during a surgical session and can be reported separately when appropriate.

Lesson 2: Posterior and Anterior Instrumentation Codes

• Objectives:
  • Differentiate between anterior and posterior instrumentation.
  • Assign the correct instrumentation code.

Anterior vs. Posterior Instrumentation

• Anterior Instrumentation: Placed on the front portion of the spinal column (vertebral body).
• Posterior Instrumentation: Placed on the back side of the spinal column (spinous process, articular facets, lamina, and pedicles).

Posterior Instrumentation Codes

• Determine if the instrumentation is segmental or non-segmental.
• If segmental, determine the number of segments.
• Code 22840: Non-segmental instrumentation. Attached only at each end, across any number of segments, or when instrumentation is placed on fewer than three segments (single fusion across one interspace and two segments).
• Interspinous wiring is uncommon but coded in the posterior instrumentation section.
• Codes are differentiated by the number of segments instrumented.

Anterior Instrumentation Codes

• Differentiated based on the number of vertebral segments instrumented.
• Not differentiated to specify segmental vs. non-segmental.

Pelvic Fixation

• Code 22848: Affixing instrumentation to a pelvic structure (usually the iliac).
• Typically used with another instrumentation code for the regular instrumentation.
• Often accompanies procedures for scoliosis, myelomeningocele, or paralytic spinal defects where sacral fixation is not desirable.

Lesson 3: Instrumentation Removal and Reinsertion Codes

• Objectives: Know when to apply instrumentation removal, reinsertion, or just instrumentation codes.

Reinsertion of Failed Devices

• Code 22849: Reinsertion of failed devices.
• This is a stand-alone procedure, not an add-on code.

Removal of Instrumentation

• Three codes are used when only removal is being performed.

CPT Guidelines for Reporting Reinsertion and Removal

• Review CPT guidelines for reporting these services.

Lesson 4: Spinal Devices

• Objectives:
  • Recognize different spinal devices.
  • Know when to use a device code or a graft code.
  • Know what services to report in addition to the spinal device.

Biomechanical or Synthetic Interbody Devices

• Codes 22853, 22854 include integral anterior instrumentation when performed.
• Devices are often referred to as PEEK cages or cages.
• Code 22853: Interbody device used in conjunction with interbody arthrodesis.
• Code 22854: Interbody device placed into a vertebral corpectomy site in conjunction with interbody arthrodesis.
• Code 22859: Interbody device placed not in conjunction with interbody arthrodesis.

Key Concepts for Reporting Spinal Device Codes

1. Integral Anterior Instrumentation:
   • Codes 22853 and 22854 include it when performed.
   • If the anchoring part of a device (screw or flange) acts as an anchor for the device into the disc space, the screw or flange instrumentation is not reported separately.
   • Device anchoring is not the same as anterior instrumentation.
   • Anterior instrumentation involves a stand-alone device for biomechanical support (e.g., anterior cervical plating or anterior rod system fixation).
   • If the plate is integrated and only used with the cage to keep it in the disc space (not acting as a stand-alone device), an instrumentation code (e.g., 22845) is not reported separately.
2. Synthetic Devices and Cages Only:
   • These codes are for synthetic devices and cages only.
   • For intervertebral bone devices or grafts, report grafting codes.
   • Structural allografts placed in the interbody space are reported with CPT 20931.
3. Reporting per Defect or Interspace:
   • Codes 22853, 22854, and 22859 can be reported per defect or interspace.
   • Grafting codes can only be reported one time, regardless of how many grafts are placed.

Interlaminar or Interspinous Process Stabilization and Distraction Devices

• These are different from interbody devices (placed between vertebral bodies).
• Interspinous spacers: Small devices implanted between the vertebral spinous processes.
• Interlaminar spacers: Implanted between adjacent lamina and spinous processes for dynamic stabilization.
• Implants are proposed to stabilize lamina or spinous processes and restrict extension to reduce pain in individuals with lumbar spinal stenosis and neurogenic claudication.
• Code 22867 and 22868: Insertion without fusion with an open decompression.
• Code 22869 and 22870: Insertion without fusion or decompression.
• Do not report open decompression at the same level as insertion of the interlaminar or interspinous process stabilization or distraction device.