Spine Coding

Spine Coding Handout Kim Wells, CPC, Julie Leu, CPC
Spine Coding:

Spinal Anatomy:

Vertebrae (33 total)
There are 5 different types 1) cervical (7); 2) Thoracic (12); 3) lumbar (5); 4) sacral (5); coccygeal (4)

The five sacral vertebrae are fused into a single bone called the sacrum. The four coccygeal vertebrae are sometimes fused into a single bone called the coccyx. Actual number of vertebral bones range from 26-29.

Vertebral segment or body is one complete vertebral bone with its associated articular processes and laminae (e.g L1, L2, L3)

Vertebral interspace is the non-bony compartment between two adjacent vertebral segments (bones). Which contains the intervertebral disk and includes the nucleus pulposus, annulus fibrosis, two cartilaginous end plates.

Vertebral levels are two adjacent segments and the interspace shared between them (e.g. L1-L2, T3-T4).

Vertebral body function is to support weight. Takes the shape of a short cylinder. Bodies of adjacent vertebrae (both suprajacent and subjacent) are connected by intervertebral disks.

Articular Processes (4 per vertebra left and right, superior and anterior). Also arise from the junction of pedicles and laminae. Superior processes project superiorly and inferior processes project inferiorly (with characteristic regional variations). Each articular process bears a facet which articulates with a facet of an adjacent vertebra form a zygarpophyseal (facet) joint.

Spinous process directly in the midline of the vertebral arch, this bony projection grows backward from the arch. The spinous process can be felt on the back as a hard knob. Three pairs of outgrowths project from the arch. One of these protrudes horizontally on each side in the thorax and connects with the ribs. The other two form joints with the vertebrae above and below. The joints permit the spine to bend flexibly.

Terminology:

Vertebral foramen a natural opening or passage in bone

Lamina an anatomical portion of a vertebra. For each vertebra, two lamina connect the pedicles to the spinous process as part of the neural arch.

Facet a posterior structure of a vertebra which articulates with a facet of an adjacent vertebra to form a facet joint that allows motion in the spinal column.

Anterior approach is towards the front of the body (may involve services of a general surgeon)

Posterior approach towards the back of the body

Diskectomy surgical removal of all or part of an intervertebral disk

Laminectomy removal of ALL of a lamina (both sides) Be sure to find out if it is a Laminectomy or a laminotomy.

Laminotomy hemilaminectomy or removal of part of the lamina, usually on one side of the vertebra

Decompression removal of pressure

Nucleus Pulposus a semi-fluid mass of fine white and elastic fibers that form the central portion of an intervertebral disk.

Conditions that necessitate spine surgery related to segmental instability

Deformity:

Scoliosis: an appreciable lateral deviation in the normally straight vertical line of the spine

Kyphosis: Abnormally increased convexity in the curvature of the thoracic spine as viewed from the side (hunchback)

Lordosis: The anterior concavity in the curvature of the lumbar spine as viewed from the side (swayback).

Segmental Instability

Fractures (22305 - 22328)

Vertebral body

Burst: A type of vertebral body fracture that can be pathological or trauma, basically from inside out. Can be likened to an explosion

Odontoid: Tooth like process of the second cervical vertebra

Infections: e.g. Diskitis or osteomyelitis

Neoplasm

Spondylolisthesis: Forward displacement of one vertebra over another. Usually L5 over the body of the sacrum or L4 over L5.

Degeneration: Bone e.g. osteoporosis

Spine procedures and related CPT Codes

Bone Grafts specific codes for spine surgery (20930 - 20938)

Allograft: A graft of tissue obtained from one person and implanted into another. It can be obtained from cadaver donors, frozen or freeze dried until transplantation.

Autograft: A graft of tissue taken from a patient and then re-implanted elsewhere in the same patient. Usually one or more pieces of bone are removed from the iliac crest for transformation between the vertebra.

Types of Grafts:

Moreselized: Pieces or crumbs of bone removed from the patient's own body or from a bone bank

Structural, Bicortical or Tricortical: Specimen of cancellous and/or bone cortex obtained from the patient's own body or bank bone, used to reconstruct vertebral segments or spinal arthrodesis. Cancellous: Spongy type of bone which usually comes from bone marrow.

Bone Grafts: The choice of code depends on whether small pieces or strips of cancellous bone are placed at the operative site(s) (Moreselized) OR whether the cancellous and/or bone cortex graft (structural) are used. In either case the graft is trimmed, fitted, and fashioned for an exact fit and to ensure adequate contact for future stability.

Per the November 1999 CPT Assistant the statement indicating that "only one bone graft code" should be reported per operative session has been deleted to clarify the reporting when more than one type of bone graft is required. This went into effect January 2000. Grafts are also exempt from the modifier 51 and are reported separately.

Arthrodesis (spinal fusion): The fixation or stiffening of a joint by surgical means. Codes reported are based upon the reason for the procedure, as well as the approach, the site, and the number of vertebrae involved.

Arthrodeses performed for spinal deformities, (e.g. Scoliosis or Kyphosis, are reported using codes (22800- 22812).

If the arthrodesis is being performed for a reason other than to correct a spinal deformity, then the codes used to report arthrodesis are classified by anatomical approaches (22548-22632)

Anterior or anterolateral approach
posterior or posterolateral approach
anterior or posterior interbody technique

Arthrodesis: The approach used by the surgeon who is performing the arthrodesis is chosen according to the underlying problem of the patient and the preference of the surgeon for treatment of this problem.

Exploration of spinal fusion (22830). If arthrodesis is performed in addition to an exploration of a spinal fusion, both procedures can be coded. Therefore, if code 22612, Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique), is performed and documented in the operative report and code 22830, Exploration of spinal fusion is performed and documented in the operative report, then both codes 22612 and 22830 can be reported.

Exploration of a spinal fusion is not considered an integral part of an arthrodesis. The 51 modifier is appended to the additional procedure to indicate multiple procedures.

Instrumentation: The use of tools, e.g. rods, hooks, wires, bolts, etc. that are used to correct and stabilize abnormalities of the spine. Will always include a graft of some kind.

Segmental: fixation at each end of the construct (rod) and at least one additional interposed body attachment.

Non-segmental fixation at each end of the construct (rod) which may span several vertebral segments without attachment to the intervening segments.

Code selection is based upon the approach and number of segments.
Posterior, non-segmental (22840)

Posterior, segmental (22842-22844)

Anterior, all segmental (22845-22847)

Prosthetic device, cage (22851)

Removal of all instrumentation

Posterior, segmental (22852)
Non-segmental (22850)

*Re-insertion, does not include removal code both (22849)
Spinal Cord and Intervertebral disk conditions necessitating spine surgery

Spondylosis: A stiffening of the articulating vertebra

Spondylolisthesis: Forward movement of the body of one of the lower lumbar vertebrae on the vertebra below it, or upon the sacrum.

Spinal stenosis: an abnormal narrowing of the spinal cord that may be either congenital or acquired (referring to neural canal)

Disk herniation: A condition that results in the abnormal herniation (bulging) of a vertebral disk from its normal position in the vertebral column.

Vertebral fractures indicated previously.

Laminectomy (63001 - 63017, 63045-63048)

Laminotomy (63020-63044)

Diskectomy, performed separately (63075-63078)

Laminectomy Coding Tips:

Code (63001 - 63011) are used for 1 or 2 segments, while (63015 - 63017) are used for more than 2 segments.

These codes (63001 - 63011, 63015 - 63017) do not include facetectomy, foraminotomy or Diskectomy.

If performed for lumbar Spondylolisthesis use code (63012)

Codes (63045 -63048) are separate from (63001 - 63017) because they include facetectomy, foraminotomy (unilateral or bilateral) WITHOUT excision of herniated disk

Use codes (63020-63044) if the procedure includes excision of herniated disk.

For partial excision of the lamina, which includes partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, use codes (63020 - 6305)

For re-exploration or revision, used codes (63040-63044)

These are unilateral procedures. Use modifier 50 if performed bilaterally.

Diskectomy Coding Tips

Code (63075) is for a single cervical interspace. Use code (63076) for each additional interspace.

Code (63077) is for a single thoracic interspace. Use code (63078) for each additional interspace.

For the lumbar interspace, contact specific insurance carrier for instructions.

The above codes are specific to the anterior surgical approach.

Spine and Spinal Cord Coding Tips:

If the procedure is completed through an operating microscope, list (69999) in addition to the primary code. Modifier 51 exempt. This procedure is bundled into most major spinal procedures according to the Medicare CCI regulations and should be verified before billing.

Codes (63035, 63043, 63044, 63048) are Add-on codes for each additional segment, reported in addition to the primary codes. Modifier 51 exempt.

When (63001 - 63048) are followed by arthrodesis, the arthrodesis is reported separately. Use codes (22500- 22632).

When multiple codes are used, list the codes with the highest RVU and follow in descending order.

Other Spinal Procedures:

For transpedicular or costovertebral approach for posterolateral extra dural exploration/decompression use codes (63055- 63066)

For vertebral corpectomy (vertebral body resection) use codes (63081 - 63091).

(61795) is an add-on code describing computer assisted planning for stereo tactic surgery. Modifier 51 exempt.

Modifiers:

Bilateral (-50) Unilateral procedure that is performed on both sides (reimbursement normally made at 150% of the regular reimbursed amount.

Multiple (51): More than one surgical procedure performed by the same physician on the same day at the same operative session.

Separate/Distinct (59) used ti identify procedures or services that are not morally reported together, but appropriate under the circumstances.

Co-surgeon (62) should not be confused with "surgical team". In spine surgery two surgeons are typically involved. One performs the open and closure of a procedure. The other performs the major clinical portion of the procedure.

When the skills of two surgeons usually with different skills are required for the performance of a specific single reportable surgical procedure, the separate services are identified by addition modifier (62) to the single, definitive procedure number used by each surgeon to report his/her services. If additional procedures (including add-on procedures are performed during the same surgical session, they are reported only by the surgeon performing the procedures DO NOT use modifier 62 with these procedures DO use modifier 51 when appropriate.
Assistant surgeon (80) used to identify the services of an assistant surgeon at a teaching facility (private payers reimburse approximately 20% of the surgical fee, while Medicare pays 16% of the Medicare allowed amount.