By Mary LeGrand, RN, MA, CCS-P, CPC

Coding for pediatric spine deformity procedures follows similar coding principles to adult spine cases. The major difference is the use of the spinal deformity codes and osteotomy codes in cases of severe scoliosis or congenital kyphosis. Laminectomy/discectomy are typically performed in conjunction with either the insertion of implants or osteotomy procedures and should not be included as a separate code.

A clearly dictated operative note defining the components of the procedure as well as the roles of co-surgeons or assistant surgeons is key to accurate coding of pediatric spine deformity procedures.

Key components
The following are common components of pediatric spine procedures:

• Spine deformity: Anterior and/or posterior arthrodesis (fusion) or kyphectomy
• Instrumentation (anterior and/or posterior, pelvic fixation)
• Grafts (allografts, autografts, interbody cages)

The following concomitant procedures are sometimes performed: osteotomy (Smith Peterson or pedicle subtraction); exploration of fusion; and removal and reinsertion of instrumentation.

Spine deformity
Whether the surgeon performs fusion or kyphectomy to correct spine deformity, the correct Current Procedural Terminology (CPT) code depends on the number of segments involved in the procedure. Table 1 shows CPT codes for anterior and posterior fusion (arthrodesis) procedures and kyphectomy for correction of spinal deformities.

In arthrodesis, the correct CPT code is based on the number of segments fused (2 segments =1 fused level). For example, if the surgeon dictates anterior fusion of T2-T5 (three segments—T2-T3, T3-T4, T4-T5), code 22808 would be reported. If fusion involved four segments (T2-T6) with an anterior approach, the appropriate code is 22810. If the dictation reflects anterior fusion of T2-T10 (eight segments—T2-T3, T3-T4, T4-T5, T5-T6, T6-T7, T7-T8, T8-T9, T9-T10), the appropriate code is 22812.

A similar approach is used for coding posterior fusion procedures for correction of spinal deformities. Because the correct CPT code to use is based on the number of segments fused, posterior fusion of T4-T7 (three segments—T4-T5, T5-T6, T6-T7) would require the use of code 22800. Dictation reflecting posterior fusion of T4-T12 (eight segments—T4-T5, T5-T6, T6-T7, T7-T8, T8-T9, T9-T10, T10-T11, T11-T12) would require the use of code 22802. Fusion that extends for 13 or more segments (such as T4-L5) is reported using code 22804.

Kyphectomy is a procedure usually performed on myelomeningocele patients to allow correction and stabilization of the deformity, decreased skin problems, increased pulmonary function, and improved sitting balance. Two CPT codes exist to describe this procedure: 22818 is used if 1 or 2 segments are involved, such as a procedure performed at T12; 22819 is used if 3 or more segments (such as T12, L1, L2) are involved. Because CPT code 22819 includes the work defined by CPT code 22818, the two codes would not be reported at the same session.

Secondary procedures
Osteotomy codes are reported when a portion of the vertebral segment is cut and removed in preparation for spinal realignment. Unlike fusion codes, which require two vertebral segments to report a one-level fusion, osteotomy codes are reported for each vertebral segment where the procedure is performed. Osteotomy codes are differentiated by spinal region (cervical, thoracic, or lumbar).

Because osteotomy procedures include laminectomy and diskectomy at the same segment, these procedures are not reported separately at the same level. Osteotomy procedures may be reported in addition to the fusion procedures when performed and documented. Table 2 shows osteotomy codes.

For example, a primary pedicle subtraction osteotomy at T7 would be coded using 22206; the same primary procedure performed at L1 would be coded using 22207. If the surgeon performed a pedicle subtraction osteotomy at T7 and T8, the surgeon would report 22206 and 22208. If the surgeon crosses anatomic locations, the surgeon reports one primary procedure code and the remaining osteotomies are reported with the add-on code.

Codes 22210, 22212, 22214, and 22216 are commonly used to report posterior osteotomy or Smith Peterson osteotomies in the spine. These codes are also reported per each vertebral segment and are differentiated by the region of the spine (cervical, thoracic, or lumbar). For example, an osteotomy at C6 would be reported with 22210; one at T7 with 22212; and one at L1 with 22214. Code 22216 would be reported for each additional vertebral segment osteotomy in addition to the primary procedure regardless of the location of the primary procedure. If the surgeon performed a pedicle subtraction osteotomy at T7 and T8, codes 22212 and 22216 would be reported.

Anterior osteotomies are reported using codes 22220, 22222, 22224, and 22226, again based on the location. An anterior osteotomy at C6 requires 22220; one at T6 uses 22222; and one at L2 uses 22224. Code 22226 is reported for each additional pedicle subtraction osteotomy in addition to the primary procedure, regardless of the location of the primary procedure. An anterior osteotomy at T7 and T8 would be reported using 22222 and 22226.

Instrumentation
The third key component is instrumentation. Instrumentation codes are selected based on the number of segments spanned, the approach (anterior or posterior), or pelvic fixation. In 2008, the status of instrumentation codes was changed from modifier 51 exempt codes to add-on codes. Refer to the AMA CPT Manual for a full listing of primary procedures (CPT codes) to which instrumentation codes may be added. Table 3 shows instrumentation codes.

For example, an anterior cervical plate placed from C3-C5 would be coded 22845; one placed from C3-C7 would be coded 22846. Code 22847 would be used for an anterior rod placed from T2-T10.

Posterior instrumentation codes are defined as segmental and nonsegmental. Nonsegmental instrumentation means that the construct has only two points of attachment; segmental instrumentation means that at least three points of attachment are used.

For example, the surgeon places pedicle screws bilaterally at L2 and L4 and then inserts a rod. Because there are only two points of attachment, this is considered nonsegmental instrumentation, even though the rod spans three vertebrae. If, however, the surgeon placed pedicle screws bilaterally at L2, L3, and L4 and then inserts a rod, the procedures would be considered segmental instrumentation.

Instrumentation code 22841 covers internal spinal fixation by wiring of the spinous processes and may not be reported with other instrumentation CPT codes. The code for pelvic fixation (22848), however, may be reported in addition to other instrumentation codes. Cages may be reported one time per interspace

Grafts
Codes 20930-20938 apply only to bone grafts used for spine surgery. CPT codes 20930 -20938 may each be reported during the same operative session but each code may only be reported one time. Bone graft codes were revised in 2008 to become add-on codes instead of modifier 51 exempt codes. This status change does not result in a change in expected reimbursement, but better defines the appropriate application of these codes in conjunction with arthrodesis procedures.

Additional Procedures
Codes 22849, 22850, 22852, and 22855 cover additional procedures such as the removal and reinsertion of devices. CPT code 22849 (reinsertion of spinal fixation device) is reported when instrumentation is removed and reinserted at the same exact level during the same operative session. If instrumentation is removed at L4-L5 and then instrumentation is placed from L2-L5, the reinsertion codes may not be reported.

CPT code 22850 covers the removal of posterior nonsegmental instrumentation (eg, Harrington rod). This code would be used if pedicle screws and rod at L1-L2 were removed without placing new instrumentation at the same level. The corresponding code for the removal of posterior segmental instrumentation is 22852, which would be used if pedicle screws and rod at L1, L2, and L3 were removed without placing new instrumentation at the same level.

Code 22855 is for the removal of anterior instrumentation, such as the removal of a cervical plate at C3-C5 without insertion of new instrumentation at the same level.

Under the AMA CPT rules, the exploration of a fusion (22830) may be reported in addition to an arthrodesis and instrumentation procedures during the same operative session. AMA CPT rules instruct the physician to append modifier 51, but many payors have an edit in place requiring the use of modifier 59 when medical necessity exists to perform the combination of procedures.

In the next column, we’ll see how these CPT codes are applied to spinal deformity procedures.

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates. The information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee. If you have coding questions or would like to see a coding column on a specific topic, e-mail aaoscomm@aaos.org