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Question: Encounter notes indicate the surgeon performed spinal arthrodesis for a patient suffering from cervicothoracic postural kyphosis. The surgeon treated 11 vertebral segments during the procedure. How should I report this encounter?

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Answer: You鈥檒l choose a single code for this surgery; the correct code will depend on the surgeon鈥檚 approach.

If the surgeon used a posterior approach, report 22802 (Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments) with M40.03 (Postural kyphosis, cervicothoracic region) appended to represent the patient鈥檚 kyphosis.

If, however, the notes indicate that the surgeon used an anterior approach, report 22812 (Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments) with M40.03 appended.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC