Multiple procedures on different spinal levels during the same session not only mean multiple codes but modifiers, too. Make the grade on your next spinal surgery medical coding claim by breaking down the following procedure.
Healthcare Coding Scenario: During a single session, your neurosurgeon performed the following procedures:
From the description you provide, your surgeon likely performed a “TLIF” procedure, also known as transforaminal lumbar interbody fusion. You should report the following codes for the claim:
If the surgeon performed the L4-L5 transforaminal interbody fusion using a posterior interbody technique, you should report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar).
For the L5-S1 interbody fusion, you should report +22632 (... each additional interspace [List separately in addition to code for primary procedure]).
You should report the appropriate autograft code (20936-20938) for the autograft.
Bill one unit of +22851 (Application of intervertebral biomechanical device[s] [e.g.,synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect orinterspace [List separately in addition to code for primary procedure]) to represent the surgeon’s work inserting the interbody cage at L4-L5.
Then, report another unit of +22851 with modifier 59 (Distinct procedural service) appended for the L5-S1 cage placement. Why: Modifier 59 shows the payer that you addressed separate levels.
Also, you should report +22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure]) for the screw instrumentation. Because the code’s descriptor refers to “3 to 6 vertebral segments,” you can report only one unit of this code, despite the fact that the surgeon inserted screws at three levels for accurate healthcare coding.
Because the neurosurgeon only documented a simple diskectomy (meaning as preparation for the fusion, not for the decompression), you wouldn’t report codes 63030-51 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, including open or endoscopically assisted approach; 1 interspace, lumbar; Multiple procedures) and +63035 (... each additional interspace, cervical or lumbar [List separately in addition to code for primary procedure]).
Remember to submit your codes listing the highest-valued CPT code first, the next-highest paying code second, and so on.
Therefore, your claim will look like this:
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