August 2004 Bulletin

Coding spinal procedures

Avoid confusion by following these tips

By Robert H. Haralson III, MD, and
Margie Scalley Vaught, CCOP, CCS-P, ACS-OR, MSC-P

When selecting the appropriate codes for spinal procedures, five basic items must be documented and supported:

This article will discuss the first three areas; subsequent articles will cover instrumentation and bone grafting.

Location

Location documents which area of the spine is being worked on: cervical (C1-C7), thoracic (T1-T12), lumbar (L1-L5) or sacral (S1-S4). Confusion arises when there is crossover of anatomic regions, such as a multiple level arthrodesis of T10-L2. Coders have wondered if more than one primary code can be reported, such as 22610 for the T10-T11, 22612 for the L1-L2 and 22614 for the additional levels.

If an arthrodesis crosses over both the thoracic and lumbar locations, AAOS recommends that you report 22612 as the primary arthrodesis code for lumbar. CPT and CMS indicate that performing an arthrodesis at the lumbar level requires more work value than one in the thoracic area. (Federal Register 2003—22612 has a work relative value unit [RVU] of 20.97; 22610 has a work RVU of 16.00)

Approach

Although there are several different approaches to the spine, the two most common are anterior and posterior. Both have sub-approaches that could be considered. The anterior approach to the cervical spine may be transoral or extraoral; the anterior approach to the thoracic spine may be thoracotomy or thoracolumbar; the anterior approach to the lumbar spine may be transperitoneal or retroperitoneal.

The posterior approach to the cervical spine is via the lamina and includes a laminectomy. The posterior approach to the thoracic spine may be transpedicular, posterolateral or costotransversectomy, and the posterior approach to the lumbar spine may be transpedicular or posterolateral.

Most CPT codes available for spinal coding are broken down into the approach selections listed above. There are occasionally some areas of confusion regarding the thoracic and lumbar areas; for example, there are no posterior re-exploration codes for the thoracic area (see codes 63040-63044), for laminotomy in the thoracic area (see codes 63020-63035), or for anterior discectomy of the lumbar spine (see codes 63075-63078). In these situations, the surgeon should be involved in the correct selection of the CPT code.

Pathology

The next key issue is the pathology of the vertebral area being worked on. Is the medical indication related to disc, spinal stenosis, scoliosis, or some other condition? Once the pathology is identified, the real coding can take place. The next question is: what is being done to correct that pathology—discectomy, decompression, corpectomy, arthrodesis or a combination of these procedures?

Discectomy—Discectomy is the removal of the intervertebral disc material that is placing pressure on neural elements. In the description of discectomy, CPT states that some form of decompression of the spinal cord may also take place along with removal of osteophytes. CPT describes code 63075 as “Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace.”

The AAOS Global Service Data (GSD) Book provides further insight into what could also be included in code 63075. According to it, code 63075 could include: “Perforation or resection of end plates; Neuroplasty for surgical exposure; Application of postop brace or head halter traction as well as preparation and placement of graft.” However, “Arthrodesis; Instrumentation; Placement of skeletal tongs or halo; and harvesting and insertion of bone graft” are excluded.

(Note: Arthrodesis by posterior interbody technique [codes 22630 and 22632] includes laminectomy and discectomy when performed to prepare the interspace for fusion. Thus, even though discectomy and laminectomy are performed in conjunction with the arthrodesis procedure, they would not be separately reported in this case. CPT Assistant, December 1999)

Corpectomy—Corpectomy is an operation to remove a portion of the vertebra and adjacent intervertebral discs to decompress the spinal cord and spinal nerves. These codes are normally reported for tumors, fractures and degenerative causes. If, however, you are reporting for degenerative changes, you need to make sure that the corpectomy is not included in other procedures performed.

CPT describes a corpectomy code such as 63081 as “Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment.” Included in 63081, according to the AAOS GSD are : “Discectomy; Excision osteophytes; Application of head halter traction, skeletal tongs if used for simple traction or postoperative orthosis; and use of magnification/loupes.” Excluded are “Arthrodesis; Instrumentation; Placement of halo; and harvesting and insertion of bone graft.”

When performing a discectomy, surgeons often drill the adjacent upper and lower endplates to remove posterior osteophytes and to improve visualization and access. This should not lead to the additional reporting of corpectomy. Many have over-coded when doing a disc space decompression, and want to report a two-level corpectomy as well. Chapter one of the National Correct Coding Initiative states:

“Some examples of generic services integral to standard of medical/surgical services would include: Surgical approach, including identification of anatomical landmarks, incision, evaluation of the surgical field, simple debridement of traumatized tissue, lysis of simple adhesions, isolation of neurovascular, muscular (including stimulation for identification), bony or other structures limiting access to surgical field.”

Arthrodesis—The sixth edition of A Manual of Orthopedic Terminology defines spinal arthrodesis as: “A procedure to remove the cartilage of any joint to encourage bones of that joint to fuse, or grow together, where motion is not desired.”

Confusion in selecting arthrodesis codes results from the use of CPT terms ‘interspace’ and ‘vertebral segment.’ Both terms are used in the arthrodesis section (22XXX series). For example, code 22630, for posterior lumbar interbody fusion (PLIF or TLIF) is defined


A spinal segment is made up of two vertebrae attached together by ligaments, with a soft disc separating them. The facet joints fit between the two vertebrae, allowing for movement, and the neural foramen between the vertebrae allows space for the nerve roots to travel freely from the spinal cord to the body.

as “Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace (other than for decompression), single interspace; lumbar,” which is normally done just in the lumbar spine area because the spinal cord is in the way in other locations. This description uses the term ‘interspace.’

However, code 22612 describes “Arthrodesis, posterior or posterolateral technique, single level; lumbar” and code 22614 states for “each additional vertebral segment.” This seems to be giving conflicting information as to how to appropriately code for multiple level arthrodesis. Fusing a single level technically includes two vertebrae and the intercalary disc. A single vertebra cannot be fused to itself, and adding another vertebra to the fusion requires the crossing of an interspace.

Whether the procedure is performed anteriorly or posteriorly, and whether the code description states segment, level or interspace, once the fusion is extended, an interspace and another vertebra must be added. A fusion from T9-L2 involves five interspaces and six vertebrae. See the illustration for clarification on the definition of a segment.

The CPT Assistant (January 2001, Vol. 11, No. 1) states: “For both codes 22554 and 22630, if the surgeon is removing disk and/or bony endplate solely with the need to prepare the vertebrae for fusion, then no additional 63000 series code(s) is reported. The appropriate 63045-63048, 63075-63078 code(s) should be reported, when in addition to removing the disk and preparing the vertebral endplate, the surgeon removes posterior osteophytes and decompresses the spinal cord or nerve root(s), which requires work in excess of that normally performed when doing a posterior lumbar interbody fusion (PLIF).”

Consequently, the coding for arthrodesis of T9-L2, posterior approach, would specify 22612 for fusing L1-L2, and 22614x4 for fusing T9-T10, T10-T11, T11-T12, and T12-L1.

Decompression—For decompression as for arthrodesis, CPT uses the terms “interspace and vertebral segment” in an inconsistent pattern. In a multiple-level decompression, the key to reporting is correlating the correct number to every root level being decompressed. The documentation should support that the dura was seen.

For example, if just the L5 roots are seen with an L4/L5 lami, code 63047 “Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; lumbar” would be reported. If both the L4 and L5 root pairs are seen in this procedure, codes 63047 and 63048 would be used. The documentation must support the root levels being decompressed.

Summary

The body of the operative note needs to support both the CPT code selection and the postoperative diagnosis to ensure appropriate coding for spinal procedures. If the surgeon indicates that a given surgical procedure is being performed for a herniated disc and decompression, other work done during that procedure may be considered inherent, unless it is separately supported.

CMS is very clear that there must be supporting medical necessity for a given procedure or service. This should be clearly supported in the operative note, such as in the indication section. Having an indication paragraph in the operative note further supports the medical necessity as well as ICD-9 coding and appropriate modifier use. When it comes to spinal procedures and coding, the surgeon and the coder should work as a team to ensure that neither overcoding nor undercoding occurs.

Robert H. Haralson III, MD, MBA, is the medical director of Southeastern Orthopaedics in Knoxville, Tenn. He is the CPT advisor for the Academic Orthopaedic Society.

Margie Scalley Vaught, CCOP, CCS-P, MCS-P, is an independent coding specialist in Ellensburg, Wash., and a member of the American Academy of Professional Coders’ National Advisory Board. She can be reached at vaught@kvalley.com


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