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You鈥檒l filter through complex documentation on these claims.

When choosing an appropriate spinal procedure code, you need to first focus on what the spinal fusion (arthrodesis) is for.

Typical procedures include decompression, diskectomy, fracture treatment, and exclusively spinal fusion. The subsequent section details the methodology for performing the spinal fusion. Keywords to look for are anterior or posterior in the note, which should offer further specifics to choose the adequate code. Neurosurgeons typically do a very good job documenting all of this in their operative reports as these are complex cases. If you are unable to locate any of these necessary components, a query to the surgeon would be advised.

Check out this advice on getting your arthrodesis surgery claims right every time.

Fusion Could Come With Other Surgeries

When the neurosurgeon performs arthrodesis, you need to be careful to code any additional surgery performed as well. An example is a diskectomy, where payers will ask if it was performed at the same or different level as the fusion site. The vertebral interspace is referring to the compartments between the vertebrae. If they are requesting vertebral segments, they are referring to each single vertebrae bone.

Other services or procedures that could accompany arthrodesis include:

• Drug-delivery device placement or removal: These can appear in the form of beads, nails, or spacers that are biodegradable/nonbiodegradable.
• Spinal instrumentation use other than for arthrodesis: If there is additional instrumentation involved, you will need the type of instrumentation and approach documented.
• Bone graft: If the surgeon uses a graft, you will need to know if it was allograft, autograft or both. Allograft is bone obtained from a bone bank or other source. Autograft includes harvest of the patient鈥檚 own bone. Specification continues filtering down to morselized (crumbled bone) or structural (bone machined and used for structural support).
• Navigation: The final piece should be verifying if a computer-assisted navigational system was used for the procedure. Spinal procedures have their own navigation code, +61783 (Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure)).

Get Specific in Diagnosis Code Selection

Be aware of the additional selections beyond the degeneration of an intervertebral disc, such as the anatomical location in conjunction with other problems the patient may be experiencing. These other problems commonly involve myelopathy, radiculopathy, neuritis, radiculitis, and radiculopathy. Pay attention to the keywords only, and, or, and unspecified to ensure proper coding.

The next portion will focus on the disc region. Be sure to code all regions involved, as different codes are necessary.

Check Out These Modifiers Commonly Used for Spine Surgeries

There are certain modifiers that you鈥檒l find yourself using often during spinal surgery. Here鈥檚 a look at a few of the most common:

• Modifier 62 (Two surgeons): Each surgeon does a distinct portion of procedure and writes separate op notes.
• Modifier 80 (Assistant surgeon): The surgeon鈥檚 statement must specify the assistant.
• Modifier 82 (Assistant surgeon (when qualified resident surgeon not available)): The surgeon鈥檚 statement must specify the assistant.
• Modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery): The surgeon鈥檚 statement should describe what the assistant helped with in the procedure and that no residents were available.

Caveat for assist/co-surgery: You need to verify that the procedure allows for the co-surgery, assistant surgeon, or physician assistant in the Medicare Physician Fee Schedule (MPFS).

Consider This Clinical Example

A 61-year-old patient presents after being diagnosed with a severely bulging disc with radiculopathy at C5-C7. Patient has been adequately informed about the anterior cervical discectomy and fusion needing to be performed, its risks, and its benefits, obtaining informed consent prior to proceeding. The spinal neuronavigational system was brought into the operative space utilizing previous imaging prior to the procedure. Surgeon began with an anterior interbody decompression arthrodesis from C5-C7. Surgeon inserted an interbody biomechanical device with anterior instrumentation for device anchoring to intervertebral disc space in conjunction with interbody arthrodesis from C5-C7. Surgeon utilized morselized allograft for this procedure. Patient tolerated the procedure well with optimal outcome.

For this encounter, you would report:

• 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) for the arthrodesis
• +22853 x 2 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)) for the device insertions
• +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure))
• +61783 for the stereotactic guidance
• M50.122 (Cervical disc disorder at C5-C6 level with radiculopathy) and M50.123 (Cervical disc disorder at C6-C7 level with radiculopathy) appended to 22551, +22853, +20930, and +61783 to represent the patient鈥檚 disc disorder.

Kalie Bothma, CPC, CEDC, CSAF, Medical Coder, Corewell Health