If the surgeon removed the screws but didn't insert new ones, you have two coding choices depending on the original procedure. Code with 22852 (Removal of posterior segmental instrumentation) if the iliac screws were part of a previous lumbar-spinal fusion. If the iliac screws were for an old pelvic fracture, your most likely choice is 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]). Append modifier 52 (Reduced services) to the procedure code to indicate the surgeon didn't remove all instrumentation. If, however, the surgeon inserted new screws, report 22849 (Reinsertion of spinal fixation device). No modifiers or other codes are necessary.
Explanation: Surgeons sometimes use iliac screws during spinal fusion cases to anchor or attach plates or rods going up to the lumbar spine. CPT includes specific codes for spinal instrumentation insertion and removal and your example definitely involves deep hardware. Because of this, you would report 22852 for the case in question instead of 20680.
Bone marrow aspiration will not be coded separately as it gets bundled into 63047/63048/22612/22614
Your final codes will be
You can't bill instrumentation removal during repeat fusions
Suppose your surgeon places segmental instrumentation during a spinal fusion, but a year later the patient returns complaining of severe low back pain, and the surgeon suspects pseudarthrosis.
The surgeon returns the patient to the operating room (OR), removes the instrumentation and explores the fusion mass (22830, Exploration of spinal fusion). The orthopedic surgeon confirms pseudarthrosis and performs a redo fusion.
"Some Medicare carriers say you can't use the instrumentation removal codes with 22830," said Greg Przybylski, MD, professor and director of neurosurgery at the NJ Neuroscience Institute at JFK Medical Center and Seton Hall University, at a May Coding Institute audioconference titled "Eight Stellar Strategies for Spine Surgery Pay-up."
Those Medicare payers are wrong, Przybylski says. "CPT added language in 2005 that states the AMA's position, which is that you can use the instrumentation removal/reinsertion codes with 22830."
The applicable removal/reinsertion codes you should report are:
•22849 - Reinsertion of spinal fixation device
•22850 - Removal of posterior nonsegmental instrumentation (e.g., Harrington rod)
•22852 - Removal of posterior segmental instrumentation
•22855 - Removal of anterior instrumentation.
Justification: CPT states, "Report modifier 51 (Multiple procedures) with 22849, 22850, 22852 and 22855 when instrumentation reinsertion or removal is reported with other definitive procedures such as arthrodesis, decompression, and exploration of fusion."
If your insurer continues to deny your instrumentation removal claims when you report spinal fusion, copy the applicable page of CPT (the notation is printed directly above code 22830's descriptor) and send it with your appeal, along with a short letter from the surgeon.