Current Procedural Terminology (CPT) is a medical code set used to report medical, surgical, and diagnostic services. CPT codes are an integral part of the billing process for health care entities and providers because the codes indicate to insurance payers the specific procedures they are seeking reimbursement for. These codes can also be used by governmental agencies to track health data including the prevalence and value of certain surgical procedures.1,2

Each CPT code is five characters long and may consist of a combination of numbers and/or letters depending on the category it falls under.1,2 The rules for assigning the appropriate codes can become quite complex, and as a result CPT coding has the potential to become a confusing and frustrating process for even the most experienced professionals. In this blog post a formulaic strategy to help ensure proper CPT coding for surgical spinal procedures will be presented to help alleviate this process and avoid common mistakes.

 

General Problems to Avoid3

  • Not coding the highest level—the highest level of specificity should be coded to accurately describe the medical, surgical, or diagnostic service
  • Failing to use current and/or updated codes—it is the responsibility of coders to learn new and/or reorganized codes updated by the American Medical Association and use them correctly
  • Under- or overcoding—reporting less expensive medical services than performed and reporting more expensive procedures than performed
  • Unbundling—false reporting designed to earn the provider a higher payout through separately coding procedures that are included in a single code

 

5 Items that must be documented and represented by the CPT code4,5

1. Location—Cervical (C1-C8), Thoracic (T1-T12), Lumbar (L1-L5) or Sacral (S1-S4)

  • If a procedure spans multiple spinal regions (i.e. arthrodesis of T10-L2) one primary spinal region is coded rather than code for each region involved separately. The region of higher work relative value is the one that is coded.

2. Approach—Anterior or Posterior

  • Sub-approaches must also be considered

3. Pathology—What is the medical indication for having spinal surgery? What is being done surgically to correct the pathology?

  • Discectomy: the removal of intervertebral disc material placing pressure on neural elements
    • Standalone codes are used to describe discectomy
  • Corpectomy: the removal of part of all of an intervertebral body
    • Corpectomy codes include in the description the discectomy at the level above and below the corpectomy, a separate discectomy CPT code is not required
  • Arthrodesis (Fusion): the joining of two or more vertebrae
    • A standalone code is usually used to describe fusion, unless decompression is also performed. In this instance, there is a single combined decompression/fusion code (22551).
    • The standalone code covers the first segment of fusion, and add-on codes are used to describe additional levels of fusion
  • Decompression
    • Standalone codes are used to describe decompression
    • Decompression codes are per “vertebral segment” or per “interspace”
    • For multiple-level decompressions, the CPT code must support the correct number of nerve root levels being decompressed

4. Instrumentation/Hardware

  • All instrumentation and hardware codes are add-on codes
  • Determine whether the instrument is non-segmental, segmental, or intervertebral
  • Non-segmental (+22840): “fixation at each end of the construct and may span several vertebral segments without attachment to the intervening segments.”
    • 2 points of attachment on the spine
    • Segmental(+22842-+22844): “fixation at each end of the construct and at least one additional interposed bony attachment”
      • At least 3 points of attachment on the spine
    • Intervertebral (+22851): any synthetic device, not considered a bone graft, which is put into the interspace or vertebral defect to promote fusion
      • Reported per interspace containing devices, not by how many devices are placed in each interspace

5. Bone grafting—Allograft (donor bone) or Autograft (patient’s bone)

  • All spinal bone graft codes are add-on codes
  • CPT guidelines allow for one bone graft code per operative session
  • Determine if the allograft or autograft is morselized (bits/pieces) or structural (wedge/chunk)
    • Allograft, morselized (+20930)
    • Allograft, structural (+20931)
    • Autograft, morselized (+20936, +20937)
    • Autograft, structural (+20938)

 

References:

 

  1. What is CPT®? Aapc.com. https://www.aapc.com/resources/medical-coding/cpt.aspx. Accessed March 18, 2019.
  2. Intro to CPT Coding. Medicalbillingandcoding.org. https://www.medicalbillingandcoding.org/intro-to-cpt/. Accessed March 18, 2019.
  3. 4.03: Common Problems in Medical Coding. Medicalbillingandcoding.org. https://www.medicalbillingandcoding.org/common-problems-coding/. Accessed March 18, 2019.
  4. Pollock K. Spine surgery coding made simple. Aapc.com. https://www.aapc.com/blog/25658-procedure-coding-made-simple/. Published September 1, 2013. Accessed March 18, 2019.
  5. Haralson RH, Vaught MS. Coding spinal procedures: avoid confusion by following these tips. Aaos.org. http://www2.aaos.org/bulletin/aug04/code.htm. Published August 2004. Accessed March 18, 2019.