Identify the type of technique (approach) that is being used
Transoral or extraoral – approach through the mouth to access the clivus-C1-C2
Anterior interbody – approach through the front portion of the body (side of the neck - key terms are sternocleidomastiod muscle, platymal muscle). Cervical below C2 is used to access C2-C7 vertebra. This is the most common type of approach for cervical fusion
Lumbar Retroperitoneal Exposure – access to the lumbar vertebra by exposure through the abdominal cavity.
Posterior or posterolateral approach – access through the posterior or back portion of the body. Posterior fixation is achieved by placement of structural graft between the vertebra and/or segmental or non-segmental fixation. Posterolateral fixation is achieved by fixation of the transverse processes.
Posterior Interbody – placement of cage(s) or device(s)
within the intervertebral space.
When there is compression of the spinal cord (spinal stenosis)or nerve roots (disc herniation) and a decompression procedure is performed to relieve the pressure, additionally report the appropriate CPT code from the 63001-63048 section of the CPT book. For example, a discectomy is performed at L4-L5 because disc fragments are irritating the nerve root then CPT code 63030 may be reported.
Insertion of Biomechanical Devices
Also know as a PEEK cage. These cage(s) are used for an interbody arthrodesis because they are placed within the disc space and reported once per level regardless of the number of cages at one level. Two cages at L3-L4 is 22851, one cage at L3-L4 and one at L4-L5 is 22851 x2. In many instances bone graft material may be packed into a cage, the bone graft is separately reported. CPT notes and CPT Assistant Jun 07; 10 instructs the coder to report 38220 for bone marrow aspiration, the bone marrow is then mixed with the bone graft material.
A threaded bone dowel is considered a biomechanical device and reported with CPT code 22851 and not a bone graft code.
20930-20931 are morcellized and structural allografts that are obtained from a bone bank.
20936-20937 are morcellized and structural autografts. These bone grafts represent “local” grafts harvested through the same incision in an area where the surgery is being performed.
20938 represents a structural autograft harvested through a separate incision.
The most common type of anterior instrumentation for cervical arthrodesis is a plate and screws.
For lumbar arthrodesis, screws can be placed through the pedicles, or rods are run along the side of the spine as part of segmental or non-segmental fixation. Segmental consists of fixation at each end of the construct (rods) and at least one point in between, non-segmental is fixation at the upper and lower ends of the construct (rods) only.
Minimal wiring using devices such as a Songer cable is not additionally reported.
When performing an “interbody” arthrodesis it is sometimes necessary to apply posterior instrumentation. You would not report an interbody arthrodesis and a posterior or posterolateral arthrodesis at the same level. In this instance, report the interbody arthrodesis and posterior instrumention codes.
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