Spinal Fusion Surgery & Its Documentation

Spinal Fusion Surgery & Its Documentation Lumbar spinal fusion surgical procedure aims at fusing together the painful vertebrae so that they heal into a single, solid bone.

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Lumbar spinal fusion is a major surgery performed to join, or fuse, two or more vertebrae in the low back. Also known as spinal arthrodesis, the major goal of this surgery is to restrict spinal motion in order to relieve painful symptoms. Orthopedic surgeons generally perform the procedure to treat and relieve symptoms of many back conditions such as degenerative disk disease (DDD), spondylolisthesis, spinal stenosis, scoliosis, fracture, infection and tumor. Orthopedics medical billing involves preparation of medical documentation with the updated spine codes published by the Centers for Medicare and Medicaid Service (CMS).

About the Surgery The surgery involves adding bone graft to a segment of the spine, setting up a biological response that causes the bone graft to grow between the two vertebral elements to create a bone fusion and the boney fusion - which results in one fixed bone replacing a mobile joint - stops the motion at that joint segment. It may be done with other surgical procedures such as spinal stenosis, foraminotomy or laminectomy.

Diverse approaches to lumbar spinal fusion surgery includes posterior, anterior and lateral. During an anterior approach, the surgeon places the patient supine (lying face up) and accesses the spine through an incision in the front of the body. A posterior approach gains access to the spine through an incision in the back (or the back of the neck) with the patient prone or face down. During a lateral extracavitary approach, the surgeon usually positions the patient on his or her side and begins an incision vertically over the spinous processes. A bone graft that is primarily used to stimulate bone healing increases bone production and helps the vertebrae heal together into a solid bone.

Spinal Arthrodesis – Reimbursement and Documentation Approval of medical claims involving such major procedures requires documentation supporting

the

reasonableness

and

necessity

of

the

procedure.

Submitted

documentation should include: ď ś History and Physical

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 Duration/character/location/radiation of pain  Activity of daily living (ADL) limitations  Physical examination  Evidence/support of prior conservative treatment measure(s) attempted  Imaging reports pertinent to performed procedure  Operative report(s)  Outpatient records before, during and after the procedure that support the medical necessity of performed procedures As there are different surgical approaches for spinal fusion, it is critical to match the approach on the surgical report to the CPT® code description, while coding arthrodesis.

Rehabilitation

and

pain

management

programs

may

also

be

recommended for recovery after surgery. Physical therapy helps to teach the patient how to move, sit, stand and walk in a manner that keeps their spine properly aligned.

CPT Coding for Lumbar Spinal Fusion Coding specialists at professional medical billing companies will identify whether the approach was posterior or anterior and choose the correct CPT arthrodesis code(s).

Posterior Lumbar CPT codes that come under “Posterior, Posterolateral or Lateral Transverse Process Technique Arthrodesis Procedures on the Spine (Vertebral Column)” are 

22612



+22614



22630



+22632



22633



+22634

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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

List these codes separately in addition to code 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

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

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

+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 For accurate documentation, medical coders must review the operative note to determine where the instrument was used, and whether it was non-segmental, segmental, or intervertebral.

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