Gina Posted Tue 04th of December, 2018 13:02:15 PM
Provider makes a skin incision, open up the cervical dorsal fascia and muscle dissection to approach the cervical facet joint. Using the flouroscopic guidance and indetifying the correct level, the access chisel was advanced,guide tube was introduced, facet joint was then decorticated and CAVUX cage was introduced in the facet joint. Would this qualify for open procedure and open fusion codes with insertion of cage should be used? Or this is considered a minimally invasive procedure and should be coded 0219T only? Manufacturer advised if skin incision, dissection, guide tube used as a retractor, and decortication was done and documented , open fusion codes can be used. Is this correct?
SuperCoder Answered Wed 05th of December, 2018 09:07:46 AM
>Our team is working on it.
SuperCoder Answered Thu 06th of December, 2018 03:33:06 AM
CPT 0219T is used when the surgeon performs minimally invasive placement of intrafacet implants without open approach arthrodesis. CPT 0219T is a procedure which is an alternative to surgical fusion. In CPT 0219T provider implants an allograft or a synthetic spacer into the facet joint of the cervical vertebrae under image guidance. This procedure expands and stabilizes the facet joint space and lessens pain due to degenerative changes or trauma in the cervical vertebrae region. On the other hand, in open fusion provider performs arthrodesis or spinal fusion to permanently join two vertebrae, the interlocking bones of the spine.
As per above mentioned documentation, surgeon is only placing CAVUX cage in the facet joint, so the appropriate code will be 0219T.
Note: In CPT 0219T provider makes an incision in the cervical region of the vertebral column, extends the incision down to the fascia and muscle, and then exposes the bone. He places a synthetic spacer or an allograft, typically made from the bone of the femur or tibia, into the facet joint at a single level of the cervical vertebra. He performs the procedure under fluoroscopic guidance or other imaging technique. Finally, the provider controls any bleeding and closes the wound in layers.
SuperCoder Answered Thu 06th of December, 2018 08:35:17 AM