Key Tips to Avoid Obsolete Spinal Coding Practices

Coding spine and pain procedures can be a complex and confusing process for both new and veteran coders. Commonly performed spine procedures include Lumbar decompression, Lumbar discectomy, Anterior cervical discectomy and fusion, Lumbar posterior inner-body fusion, Spinal cord stimulator and Radiofrequency ablation. According to Becker’s ASC Review, medical coders at hospitals as well as at medical coding companies, who stay updated on the latest regulatory billing and coding guidelines and changes in payers’ individual medical policies, are more likely to see claims approved on the first submission – a major boon to an ASC’s bottom line.

According to reports, spine and orthopedic surgery practices often experience revenue shortfalls due to inaccuracies in coding and billing processes. Main procedures such as fusion, grafting, instrumentation, osteotomy and fracture treatment must be perfectly documented for on-time reimbursement. Make sure that your coders have a strong understanding of spine anatomy and they are skilled enough to choose the appropriate codes each time.

Becker’s ASC Review’s February 2018 blog discusses key challenges physician practices face in spinal coding, which include CPT coding confusion and/or misunderstanding of strict coding guidelines, CPT code changes for how and which growing number of medical devices are used in spinal procedures, increasing complexity of shoulder procedure codes as well as higher payer scrutiny on spinal discectomy procedures overall.

Keep up-to-date with the changing spine coding guidelines. Here are a few to check.

Coding fusion levels

A spinal fusion is the procedure performed to join 2 vertebral bodies. It involves the removal of the disc material in between the 2 vertebral bodies. if the surgeon documents posterior fusions of the L1-L5, there are four fusion levels: L1/2, L2/3, L3/4, and L4/5. Here is how to report this.

• 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)
• +22614 each additional vertebral segment (List separately in addition to code for primary procedure) x 3

For interbody fusions, count the structures being removed between the two vertebral bodies. This is reported using:

• 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar
• +22634 each additional interspace and segment (List separately in addition to code for primary procedure) x 3

For double posterior fusions (interbody and posterolateral), count the structures removed between the two vertebral bodies (L1-L5) – also four levels. This is reported using:

• 22633Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar
• +22634 each additional interspace and segment (List separately in addition to code for primary procedure) x 3
  In fusion surgeries, make sure to check what type of implants the physician has used, as implants are covered under specific CPT codes. Also code for whether it is a first-time implant, removal or revision surgery.

Decompression

Decompression procedures such as laminectomy, discectomy and corpectomy refer to removal of the spinal disk, bone, or tissue causing pressure and pain. When reporting nerve root decompression, you must know how many nerve roots were decompressed. For example, if the surgeon documents nerve root decompression of L4/5, then you must clarify whether it was the L4 and L5 nerve roots, or only the L4. The Center for Medicare & Medicaid Services (CMS) – via the National Correct Coding Initiative (NCCI) has recently bundled 63047 and +63048 codes into 22630 and 22633.

• 63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar).
• +63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)

As a result of this change, decompression is unbillable if performed at the same level(s) as arthrodesis.

Nerve roots decompressed at different levels from the arthrodesis can be reported separately. For example, if a surgeon performs posterolateral fusions at L1-S1, with an interbody fusion at L5/S1 (22630, 22614 x 4) with nerve root decompressions of L3 and L4 nerve roots, you can report 63047 and 63048 with modifier 59 Distinct procedural service appended because the decompressions were not done at the same level as the interbody arthrodesis (22630).

If your hospital receives denials when reporting 63047/63048 with 22630/22633 at the same level(s) from payers who do not follow NCCI edits, it is recommended to get a copy of the May 2018 CPT® Assistant as evidence in your appeal process. Remember that to use the corpectomy codes, documentation also should reflect removal of at least 50 percent of the cervical vertebral body, or 33 percent of the thoracic and lumbar vertebral bodies.

Spinal instrumentation

Instrumentation is the hardware implants used in spine surgery, which is done to restore stability to the spine, correct deformity and bridge the space created by the removal of intervertebral discs. It comes in two basic varieties: devices placed within the intervertebral space or confined to a single vertebral segment, and devices placed across two or more vertebral segments. If instrumentation is used in fusion, choose the appropriate add-on code(s) for the same.

Do not report instrumentation removal codes with insertion instrumentation codes for the same session.

Non-segmental instrumentation is defined by CPT® as “fixation at each end of the construct and may span several vertebral segments without attachment to the intervening segments”. It is coded using

• +22840 Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation)

Segmental instrumentation is defined as “fixation at each end of the construct and at least one additional interposed bony attachment,” which refers to at least three points of attachment on the spine. It is documented using codes

• +22842 Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments
• +22843 Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments) and
• +22844 Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments.

The use of cages as instrumentation can be reported using codes such as +22853, +22854 and +22859. These codes differ with the reasons why the cages are placed, such as you have to use 22853 when a metal cage is placed for an interbody fusion (either anterior or posterior); 22854 when a metal cage is placed with corpectomy and interbody fusion; and 22859 when a vertebral body is removed, and a custom-made metal cage is inserted but no interbody fusion takes place.

A thorough reading of the operative report and close attention paid to the coding guidelines can help coders avoid complexities in the process. HIPAA-compliant orthopedics medical coding services provided by experienced medical billing companies could help ensure accurate and timely claim filing and reimbursement.

For more details, read our blog on billing and coding spine procedures.