Coding spinal fusions is confusing enough, but coding them when the surgeon used spinal instrumentation is even more perplexing. And thanks to the many significant CPT code changes in 2017 and 2018, you have a lot on your plate to figure out before you can even begin to select the right codes.
Pay attention: The 2018 changes to the Centers for Medicare & Medicaid Services’ (CMS’) National Correct Coding Initiative (NCCI) Policy Manual will alter the way you report spinal instrumentation, orthopedics coding expert Lynn M. Anderanin warns in the ProfEdOnDemand session, “Coding for Spine Surgery and Co-Surgery.”
Know Your NCCI Updates
Important: Effective Jan. 1, 2018, CMS has revised the NCCI guidelines for coding CPT codes 22853 and 22854, particularly when reporting anterior instrumentation. The NCCI guideline changes in Chapter IV of the NCCI Policy Manual read as follows:
“CPT codes 22853 and 22854 describe insertion of interbody biomechanical device(s) into intervertebral disc space(s). Integral anterior instrumentation to anchor the device to the intervertebral disc space when performed is not separately reportable. It is a misuse of anterior instrumentation CPT codes (e.g., 22845-22847) to report this integral anterior instrumentation. However, additional anterior instrumentation (i.e., plate, rod) unrelated to anchoring the device may be reported separately appending an NCCI-associated modifier such as modifier 59.”
These changes come on the heels of the 2017 CPT revision that deleted code 22851 and replaced it with three new codes: 22853, 22854, and 22859.
The most common code used when reporting spinal instrumentation is 22853, stated Lynn Thornton, RHIA, CCS in a recent tutorial for MedPartners. You can use CPT code 22853 for spinal procedures where the approach is anterior or posterior.
The catch: As CPT and the NCCI update state, you should not separately report anchoring the device. “CPT states that 22853 includes the placement of any anterior integral instrumentation,” Thornton said. “This means that the anterior plate is necessary to use with the device (cage). The plate/screw(s) are used to secure the cage to the fused vertebrae.”
You should report only CPT code 22853, and don’t try to separately report or unbundle CPT code 22845 if the surgeon used an integrated plate to secure the device into the interspace, Thornton stressed. This is also true when the surgeon places an intervertebral device with an integrated anterior plate (also called a “low profile” or “stand-alone” device).
Look for Additional Instrumentation
But when can you report spinal instrumentation using both CPT code 22853 and 22845? You should look to the surgeon’s documentation in the operative report to pinpoint the specific trade name of the spinal implant so you can report the correct codes, advised Kim Pollack, RN, MBA, CPC, CMDP, a senior consultant with Karen Zupko & Associates, Inc., in a recent report.
The surgeon should document in the operative report whether she secured the cage or device with the instrumentation, Thornton noted. If the surgeon used additional instrumentation that she did not secure or anchor to the device, then you would report that separately.
Try this: You can also research a documented specific device online, as many manufacturers have reimbursement guides with coding advice on their websites, Thornton added. For example, you would code separately specifically documented devices such as “ViZia Anterior Cervical Plate System” when inserted during a fusion.
Code 22854 the Right Way
Finally, you should report CPT code 22854 when the surgeon places an intervertebral device into a corpectomy (removal of the vertebral body) defect and performs arthrodesis, according to Pollack.
Example: The surgeon performed a C6 corpectomy with discectomies at C5-C6 and C6-C7, and with preparation of the C5 and C7 endplates, Pollack illustrated. The surgeon placed into the corpectomy defect an expandable titanium cage packed with bone graft for arthrodesis, and secured a plate to C5 and C7. In this case, you would report the expandable titanium cage using 22854 because the surgeon placed it in a corpectomy defect and performed arthrodesis.
Bottom line: Understanding the latest coding changes and guidelines is essential to getting the reimbursement you deserve. And following the 2018 NCCI Manual guideline changes related to biomechanical devices is critical to correct coding and payment, Anderanin stresses.
