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Anterior Hardware

Caralee Posted Wed 27th of November, 2013 10:20:37 AM

Pt. had ACDF at c3-c5 previously. Pt. is going for c2-c3 ACDF. The Surgeon is going to remove C3-C5 anterior plate and use C2-C4 anterior plate and screws. Need help with instementation/hardware codes.

SuperCoder Answered Thu 28th of November, 2013 09:05:54 AM

According to the American Association of Neurological Surgeons (AANS), all allograft bone other than a threaded allograft bone dowel is coded as +20931. You should use +22851 when your physician uses a synthetic device.

Keep in mind: If your physician uses a synthetic device or threaded bone dowel, you can report +22851 once for each level. Even if the neurosurgeon places more than one threaded bone dowel at a particular level, you should still report the code just once for that interspace. For instance, if the surgeon places two cages or two bone dowels at interspace L4/L5, you should report a single unit of +22851.

You may report additional units of +22851 for additional interspaces the neurosurgeon treats. For example, if the surgeon places two cages at L4/L5 and a third cage at L5/S1, you should report +22851 x 2.

To report an anterior cervical diskectomy with fusion (ACDF) accurately, make sure that the documentation distinguishes minimal diskectomy, which is part of the arthrodesis, from an extensive diskectomy with decompression as required for ACDF.

What is ACDF? ACDF consists of three basic steps:

1). The surgeon approaches the cervical spine through an incision in the front of the neck to remove disks and/or bone spurs that may be compressing the spinal cord and/or nerve root (diskectomy with decompression). The surgeon typically removes bone from around the area of the excised disk and then;
2.) places bone grafts to stabilize the spine, and;
3.) fuses the adjacent vertebrae, often also using titanium plating (instrumentation).

If You Claim Diskectomy, Document "More Than Minimal"

When reporting arthrodesis (22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2) and diskectomy (63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) during the same operative session, you must indicate that the surgeon performed an extensive diskectomy to receive separate payment for 63075.

Insurers often reduce or deny claims for 63075 during ACDF because the descriptor for 22554 specifically includes minimal diskectomy to prepare the interspace. Therefore, your documentation must clearly support 63075 by describing the surgeon's decompression of the neural elements and removal of 1.) any fibrovascular scar tissue over the dura; 2.) any disk material on the far lateral sides; and 3.) any osteophytes (bone spurs) that may be present, Allen stresses.

Appeal if you have to: If you receive a rejection for a properly documented diskectomy with decompression (63075) and fusion (22554), be sure to contact the payer and explain that the services are distinct and deserve separate payment. Many carriers have set up computer edits to catch and reject certain coding combinations. These edits cannot determine the extent of the services the surgeon provided, and consequently, some legitimate claims (including many ACDF claims) suffer rejection.

Rely on -59: To further support your coding, you may append modifier -59 (Distinct procedural service) to 63075 to further differentiate it from 22554.

Turn to +22585 and +63076 for Additional Levels

If the surgeon performs fusion and/or diskectomy at more than one interspace, you should account for the additional level by reporting add-on codes +22585 (Arthrodesis,... each additional interspace [List separately in addition to code for primary procedure]) and +63076 (Diskectomy... cervical, each additional interspace [List separately in addition to code for primary procedure]) as appropriate, Allen says.

Example: The surgeon performs diskectomy with nerve decompression and removal of bone spurs at interspaces C3/C4 and C4/C5, followed by fusion at both levels. You would report 63075 for diskectomy at the initial interspace and 63076 for the second interspace. Likewise, you should claim 22554 for fusion at the first level and 22585 for fusion at the subsequent level.

Remember: You don't need modifiers for add-on codes. The CPT code descriptors for add-on codes define these procedures as "in addition to code for primary procedure," and therefore multiple-procedure rules do not apply.Tip: Don't bill separately for operating microscope. Surgeons often employ an operating microscope during diskectomy with decompression.You should not, however, report +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) in addition to 63075/+63076. CPT defines use of the operating microscope as an inclusive component of diskectomy.

Report Bone Grafts Separately

Finally, you should report bone grafts independently of arthrodesis. Neither CPTnor CMS bundles arthrodesis and bone graft. Generally, surgeons will place one of two types of bone grafts during ACDF:

20931 -- Allograft for spine surgery only; structural
20938 -- Autograft for spine surgery only [includes harvesting the graft]; structural, bicortical or tricortical [through separate skin or fascial incision].
You should choose 20931 (allograft) if the surgeon uses bone taken from a bone bank or cadaver. Select 20938 (autograft) if the surgeon uses bone taken from the patient's own body.

Don't overcode: You should report only one code unit per type of bone graft, "regardless of the number of vertebral levels being surgically fused (i.e., not once per spinal interspace or segment fused)," according to the January 2004 CPTAssistant.

Example: During the same surgery described in the previous example, the surgeon places grafts taken from the bone bank at the C3/C4 and C4/C5 interspaces. In addition to reporting the diskectomy and arthrodesis codes (as above), you should claim 20931 to describe placement of the allografts. Although the surgeon placed bone grafts at two levels, you should claim only a single unit of 20931.

Remember instrumentation: Lastly, bill for anterior instrumentation, if the surgeon places it, by using 22845 (Anterior instrumentation; 2 to 3 vertebral segments) or 22846 (...4 to 7 vertebral segments).

Check Your Payments Carefully

When receiving payments for ACDF (or any multi-code procedure), check your explanation of benefits (EOB) to be sure the payer has reimbursed you properly.

The payer should reimburse you 100 percent for the most extensive procedure and 50 percent (not 25 percent) for all subsequent primary procedures, Medicare multiple-procedure guidelines stipulate.

Additionally, add-on codes (such as +63076), bone graft and instrumentation procedures are not subject to multiple procedure reductions. If you feel your payer has reduced the value of your claim inappropriately, appeal.

Caralee Posted Tue 03rd of December, 2013 08:03:53 AM

How about hardware removal codes?

SuperCoder Answered Thu 05th of December, 2013 21:22:33 PM

If your surgeon is actually removing and replacing hardware at the same spinal levels, then you can bill 22849, for reinsertion of spinal fixation device. Carriers will usually pay for this along with 22855. Sometimes the patient may have a pseudarthrosis and they will have to remove instrumentation and re-do the fusion.

But 22849 doesn’t apply if your surgeon is removing hardware from one level and placing it at another level for separate reasons.

Bottom line: You probably shouldn’t bill 22855 with 22845, even with a modifier, unless you can show that either the levels of the spine are different, or the type of hardware removed did not require additional implantation.

Also, some carriers won’t pay for anterior instrumentation removal code 22855 in the same session as anterior instrumentation code 22845. They argue that removing an existing deep-buried instrumentation from the spine is an essential part of any arthrodesis, so it should be bundled with the insertion of the replacement item.

The answer to these problems is communicating with your carrier, say experts. You may have to submit a lot of data and have your doctor write a “letter of justification"

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