Spinal Fusion – Documentation Requirements and Coding

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Spinal Arthrodesis - a Billable Procedure

• Lumbar spinal fusion is a surgical procedure
  performed to fuse together the painful vertebrae
  so that they heal into a single, solid bone
• Orthopedic surgeons perform spinal fusion
  surgery or spinal arthrodesis to restrict
  spinal motion in order to relieve painful
  symptoms.
• Orthopedics medical billing involves preparation
  of medical documentation with the updated
  spine codes published by the Centers for
  Medicare and Medicaid Service (CMS).

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Documentation Requirements

• Approval of claims entailing major procedures
  requires documentation supporting the
  reasonableness and necessity of the procedure.
• Physicians must make sure that the submitted
  documentation includes
• History and Physical
• Duration/character/location/radiation of pain
• Activity of daily living (ADL) limitations
• Physical examination

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CPT Coding for Spinal Arthrodesis

• It is critical for practices to report the
  correct CPT arthrodesis code(s), based on
  whether the approach was posterior or
  anterior.

CPT codes for Posterior Lumbar

• Posterior, Posterolateral or Lateral Transverse
  Process Technique Arthrodesis Procedures on
  the Spine (Vertebral Column)
• 22612, 22614, 22630, 22632, 22633, 22634

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Codes for Anterior Lumbar

• Anterior or Anterolateral Approach Technique
  Arthrodesis Procedures on the Spine (Vertebral
  Column)
• - 22558, 22585
• For anterior approach to reach the damaged
  vertebrae, with an incision made through the
  neck for cervical vertebrae
• - 22554 Arthrodesis, anterior interbody
  technique, including minimal discectomy
  to prepare interspace (other than for
  decompression) cervical below C2
• For resection of a single vertebral body
• - 63081 Vertebral corpectomy (vertebral
  body resection), partial or complete,
  anterior approach with decompression of
  spinal cord and/or nerve root(s)
  cervical, single segment

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Codes for Primary Procedure

• If the physician prepared and inserted an
  allograft
• - 20931 Allograft, structural, for spine
  surgery only
• For the anterior instrumentation of two to three
  vertebral segments
• - 22845 Anterior instrumentation 2 to 3
  vertebral segments

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Lateral

• For the initial thoracic level the surgeon
  treats using lateral extracavitary approach
• - 22532 Arthrodesis, lateral extracavitary
  technique, including minimal discectomy to
  prepare interspace (other than
  decompression) thoracic
• For each additional level the surgeon treats
  beyond the initial thoracic level, report
  add-on code
• - 22534 Arthrodesis, lateral extracavitary
  technique, including minimal discectomy to
  prepare interspace (other than
  decompression) thoracic or lumbar, each
  additional vertebral segment
• For procedures contained to the lumbar region
• - 22533 Arthrodesis, lateral extracavitary
  technique, including minimal discectomy to
  prepare interspace (other than
  decompression) lumbar

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CONTACT

• Professional medical billing and coding
  companies provide the services of
  experienced medical coders.
• Medical coders review the operative notes to
  determine where the instrument was used, and
  whether it was non-segmental, segmental, or
  intervertebral and assign the correct medical
  codes.

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