Spine coding is somewhat similar to a couple of other areas of CPT including interventional cardiology and interventional radiology where component coding is a major part of how procedures are described. Read this expert healthcare coding article for more.
Component coding means that there will typically multiple codes that describe different components of a total single operative procedure. And in spine surgery, there are generally four principle components that need to be considered. They are primary codes meaning they're standalone codes that if done together will typically take the -51 modifier. Those would be decompressions or removal of tissue to make more room to make more room for the spinal cord or nurse and arthrodesis which is fusion or joining together of one bone to another.
And sometimes these are done by themselves but in many circumstances, they are done together as well. Other primary components that may or may not exist in an operative procedure include spinal instrumentation which we've already learned are add-on codes. And then finally bone graft harvest for arthrodesis and the harvest itself is considered an additional component also in add-on code.
Now, the add-on codes do not take the -51 modifier. Additional add-on components to think about include microdissection which is applicable to most spinal surgery codes but is not necessarily paid for by many payers including CMS. For example, posterior lumbar discectomy and posterior lumbar laminectomy codes for decompression for this disease or spinal stenosis. Although CPT allows the use of the microdissection code 69990, many payers including Medicare will not cover it.
And the other additional add-on component is spinal navigation which is 61795. So in revealing an operative note, it's important to look at the note for all of these components knowing for well that in many circumstances, one or more of these may not be done. But if you're looking for them, then you won't miss one of them.
What we’d like to talk about now is a concept of decompression which is often a confusing point and trying to just find how many levels of how many decompression codes should be used. And the confusion has to deal with bone segment versus neurologic decompression.
A number of years ago, there were some efforts made to revise the introductory language to make this more clear. But it still remains an area of confusion. Somebody did a complete L5 laminectomy, one would certainly expect the single CPT code to describe that L5 decompression.
However, if you think about what the principle of decompression is, it's the decompressed neurologic tissue. And the anatomy of the lumbar spine is such that the decompressed nervous tissue like an existing nerve route or a passing nerve root, you often have to remove parts of two bones in order to be able to access a single nerve. So the healthcare coding example that we've provided for neurologic decompression is an L4 5 laminectomy for L45 stenosis.
Now, patients will L45 stenosis often have a single level nerve root problem with an L5 radiculopathy. But because the bones of the lamina are like shingles on the roof and overlap, parts of the bottom of L4 and the top of L5 have to be removed in order to access what's called the lateral recess or the space where the L5 nerve is compressed.
So technically, even though two bones are removed, you're doing a single level of decompression and therefore single use of 63047 would properly describe that procedure.
Arthrodesis is a little bit more straightforward and that what is simply counting the number of interspace is fused. It doesn’t matter how big or small the gap is. It doesn’t matter if the gap covers more than one interspace. It really reflects how many joints are fused to define how many arthrodesis codes would be chosen.
Keep in mind that there are different ways to perform arthrodesis not only anteriorly versus posteriorly but even posteriorly, there are poster lateral fusions as in the second bullet with code 22612 and posterior lumbar body fusion code 22630.
Medical Coding Guideline: Now although there's no CPT preclusion from coding multiple arthrodesis codes at the same level, there was a period of six months where CMS would not pay for arthrodesis performed both posterior laterally and for a posterior lumbar interbody fusion as in the example in the second bullet.
The rationale was a posterior fusion as a posterior fusion. And it's the physician’s choice as to where they do it but doing it in more than one location for the same joint should not be separately reimbursed.
After a discussion of the difference in incremental work and the rationale for potentially performing three column arthrodesis, the 22630 code essentially describes fusion of the first two column, the anterior and the middle column where as the 22612 code typically describes either the posterior column alone or with some overlay to the middle column. But typically it's the posterior column alone.
So these are really fusions of different columns of the spine. And there are some circumstances that one may need to do three column fusion surgery. And since then, CMS has reversed that position. Keep in mind that it's irrespective of whether one is using a single graft to fill the space or multiple graft, the arthrodesis is based on the number of joints that are fused.
While we look at instrumentation codes, most of these are now add-on codes and require primary code to be added on to. None of the add-on codes except the 62 code surgery modifier, you can use more than one preoperative session.
And even though the decompression codes in many healthcare coding circumstances are accepted primary codes for instrumentation codes, some payers, based on historical precedent still expects the concurrent arthrodesis code whenever an instrumentation code is used. Some difficulties exist in describing staged percutaneous instrumentation.
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