Exploration of spinal fusion Coding Simplified

Spinal fusion surgery is a medical procedure that involves joining two or more vertebrae in the spine. This procedure is used to treat several conditions such as spinal instability, deformities, or injuries. Sometimes, it is combined with other procedures to address specific spinal issues comprehensively.

When a spine surgeon performs the removal of hardware and exploration of fusion in conjunction with a redo fusion and/or an adjacent level fusion with the insertion of hardware, they tend to code for the following:

1. Removal of hardware

2. Exploration of fusion

3. Redo/adjacent level fusion

4. Insertion of spine hardware

However, there are very few scenarios where all of these codes will be paid. As a general rule, the following applies to this type of procedure:

1. Removal of hardware and insertion of hardware are not payable on the same claim.

2. Exploration of fusion is not payable with a redo or adjacent level fusion, although there are exceptions to this rule.

It is important to understand when an exploration of fusion (CPT 22830) can be paid/appealed.

Exploration of the surgical field is a common surgical practice. Healthcare providers should not report an HCPCS/CPT code that describes the exploration of a surgical field with another HCPCS/CPT code that describes a procedure in the same surgical field. For example, CPT code 22830 describes the exploration of a spinal fusion. CPT code 22830 should not be used with another spine procedure in the same anatomic area. However, if the spinal fusion exploration is performed in a different anatomic area than another spinal procedure, CPT code 22830 may be reported separately with modifier 59 or XS.

To report instrumentation procedures, see 22840-22855, 22859. (Codes 22840-22848, 22853, 22854, and 22859 are reported in conjunction with code[s] for the definitive procedure[s]. When instrumentation reinsertion or removal is reported in conjunction with other definitive procedures, including arthrodesis, decompression, and exploration of fusion, append modifier 51 to 22849, 22850, 22852, and 22855.) Code 22849 should not be reported with 22850, 22852, and 22855 at the same spinal levels. To report the exploration of fusion, see 22830. (When exploration is reported in conjunction with other definitive procedures, including arthrodesis and decompression, append modifier 51 to 22830.)

Some procedures, such as spine surgeries, frequently use intraoperative neurophysiology testing. The physician performing an operative procedure should not report intraoperative neurophysiology testing (HCPCS/CPT codes 95940, 95941, and G0453) since it is included in the global package. However, if performed by a different physician during the procedure, it is separately reportable by the second provider/supplier. The physician performing an operative procedure should not bill other 9XXXX neurophysiology testing codes for intraoperative neurophysiology testing (e.g., CPT codes 92585, 95822, 95860, 95861, 95867, 95868, 95870, 95907-95913, 95925-95937) since they are also included in the global package.

Spinal arthrodesis, exploration, and instrumentation procedures (CPT codes 22532-22865) and other spinal procedures include manipulation of the spine as an integral component of the procedures. CPT code 22505 (Manipulation of the spine requiring anesthesia, any region) should not be reported separately.

Many spinal procedures are grouped into codes with separate primary procedure codes describing the procedure at a single vertebral level in the cervical, thoracic, or lumbar region of the spine. Within some families of codes, there is an add-on code (AOC) for reporting the same procedure at each additional level without specifying the spinal region for the AOC. When multiple procedures from one of these families of codes are performed at contiguous vertebral levels, a provider/supplier should only report one primary code within the family of codes for one level and use the AOC(s) in the family of codes to report additional contiguous levels. The reported primary code should correspond to the spinal region of the first procedure. If multiple procedures from one of these families of codes are performed through separate skin incisions at multiple vertebral levels that are not contiguous and in different regions of the spine, the provider/supplier may report one primary code for each non-contiguous region. For example, the family of CPT codes 22532-22534 describes arthrodesis by lateral extracavitary technique. CPT code 22532 describes the procedure for a single thoracic vertebral segment.

CPT code 22533 describes the procedure for a single lumbar vertebral segment. CPT code 22534 is an AOC describing the procedure for each additional thoracic or lumbar vertebral segment. If a physician performs arthrodesis by lateral extra cavitary technique on contiguous vertebral segments such as T12 and L1, only one primary procedure code (i.e., the one for the first procedure) may be reported. The procedure on the second vertebral body may be reported with CPT code 22534. If a physician performs the procedure at T10 and L4 through separate skin incisions, the provider/supplier may report CPT codes 22532 and 22533. CPT codes 22510-22512 represent a family of codes describing percutaneous vertebroplasty, and CPT codes 22513-22515 represent a family of codes describing percutaneous vertebral augmentation. Within each of these families of codes, the provider/supplier may report only one primary procedure code and the add-on procedure code for each additional level(s), whether the additional level(s) are contiguous or not.