Coding and Compliance: Ensure Spot-On Spinal Surgery CPT and ICD-9 Coding


Read this expert medical coding and compliance advice to pick accurate CPT codes, ICD-9 codes for spinal surgery coding.

When looking at bone graft codes, a number of years ago, the CPT introductory language described use of bone graft codes only once per operative session. And that language disappeared after discussion with the CPT editorial panel identifying the increased frequency of much more complex spinal surgery that required multiple sources of bone grafts both from the patient as well as from a donated bone. Bone from the patient is described as autograft bone. And typically is either cancellous bone described as 20937 or a structural bone described as 20938.

There is another autograft code 20936 that describes local autograft from within the incision that you've done to do the spinal surgery itself. Things like ripped graft when doing thoracic spinal surgery or spinous process graft whenever doing any posterior cervical thoracic or lumbar spinal surgery.

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You can now use these more than once. But they may or may not be paid by the payer and it's recommended that your best chance to be paid for these is if one is using different types meaning always a different code or different sides of the body or different sources.

It is not meant for a surgeon to take a structural graft of the ileac crest 20938, cut it up into three pieces and use 20938 three times for a three level anterior cervical discectomy. That would be considered one use of 20938.

Now, to go to junctional surgery which is a very challenging medical coding area for many coders, it depends on whether you're dealing with anterior or posterior surgery and it depends on where you are in the spine as to how to choose the appropriate primary code.

If you look at anterior medical coding of a spinal surgery, the arthrodesis additional level codes are the same for all spine regions. So you have 22585 that describes an additional level arthrodesis irrespective of whether this is in the cervical, thoracic or lumbar spine.

So for arthrodesis, it's fairly simple. Pick the highest valued anterior arthrodesis code if you're crossing a junction like cervical thoracic or thoracic lumbar. And then use the 22585 code for the additional levels.

In decompression, the codes are specific for spinal region. So there is a specific anterior cervical code, a specific anterior thoracic code. The add-on codes are specific to the spinal region, there's an add-on cervical code and an add-on thoracic code.

So if you're at the junction of cervical thoracic, depending on the approach, are you approaching this via a chest opening approach than you'd use the thoracic code? If you're using a slow cervical approach, then you'd use the cervical code. And then the add-on code for that appropriate area.

Posteriorly, the add-on codes are the same for all spinal regions. So decompression codes are the same whether you're in the cervical thoracic or lumbar for add-on. So for example, 63045 through 63047 describes thoracic and lumbar decompressions for the primary level. But the additional level is 63048 for all of those.

The same is true for arthrodesis. So typically, if you'll look at the valuation of decompression and arthrodesis codes, they're often based on the location and the spine and the risk to the spinal cord. So in general, cervical and thoracic tend to be valued higher. If you'll look at lumbar arthrodesis because there is much more muscle tissue to get through for lumbar arthrodesis, then thoracic arthrodesis at the lumbar spine, the lumbar codes tend to be higher value than the cervical spine. The cervical ones are higher valued.

And the advice would be just look at the fee schedules to be able to determine which you would choose as the primary code and then you would use the generic add-on code for any additional levels.

There are also posterior regional codes. For example, a thoracic laminectomy for removing an intraspinal tumor. These do not specify how many lamina are removed when using the posterior regional codes. You really only use one code even if you're transitioning into an adjacent area. So if it's a cervical thoracic laminectomy for a junctional tumor where most of the tumor is, that's the single primary code that you choose.

If you do significant additional junctional work meaning you're taking out three, five, seven additional lamina, then it would be appropriate to code a second regional code with the -51 modifier.

Moving on to operative dictation, this is always a point of controversy among surgeons and coders with respect to including or not including ICD9 codes and CPT codes within the operative dictation.

In general, unless a surgeon is very, very familiar with both ICD9 coding and CPT coding, that is typically best left off to those with experience and expertise in medical coding and billing. However, we do advocate that the surgeons learn the language or terms of both ICD9 and CPT so that it becomes easier for someone reading the operative note to know which CPT codes to apply to a particular set of procedures.

It's important to link procedure codes with the ICD9 codes. A procedure is typically done for a specific reason. And the reason may not be the same for each different component. For example, decompression and arthrodesis are typically done for different reasons.

And finally, an operative indications paragraph is critical to reduce the incidents of denial for medical necessity. An operative findings paragraph is also advised and is important if one is going to use the -22 modifier to ask for additional payment above and beyond that which is typical.

Coding and Compliance Tip: Choose Correct Modifiers

Ensure that you select appropriate modifiers to the spine and we'll start out with that same -22  modifier or the unusual procedural services modifier.

When the relative value update committee reviews and makes a recommendation to Medicare for a value of a particular procedure, it is typically based on a typically patient. It is understood that some patients will have a more challenging procedure and some will have a more easy procedure to perform for the same type of service. There's an expected bell-shaped curve of difficulty between the easiest and the hardest. And that's why the RUC typically looks at the median values of time intensity in making recommendations to CMS.

But there may be circumstances where the procedure is substantially different from the typical average patient that you perform the procedure on. It takes more time for whatever reason. And there should be and there is using the -22  modifier a mechanism for additional payment.

And this is typically applied in circumstances where there may have been prior surgery, radiation therapy, infection, trauma or morbid obesity. However, because you're asking for additional payment above and beyond the fee schedule allowable, expect that the claim will be manually reviewed.

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