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AAOS Now

Published 9/1/2008
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Mary LeGrand, RN, MA, CCS-P, CPC

Coding for pediatric spine deformity procedures

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

Coding for pediatric spine deformity procedures requires a clearly dictated operative note defining the components of the procedure as well as the roles of the co-surgeon or assistant surgeon. This can best be seen by applying key coding concepts to several pediatric surgical case scenarios.

Note: In all cases, the 2008 relative value units (RVUs) shown are calculated without Geographic Practice Cost Index or Budget Neutrality adjustments.

Case 1: Posterior fusion with Smith Peterson osteotomies
An orthopaedic surgeon operates on a 15-year-old boy with progressive idiopathic scoliosis and pulmonary insufficiency. The surgeon dictates the following operative note:

“Posterior fusion of T1-L4; posterior segmental instrumentation of T1-L4; Smith Peterson osteotomies at T7, T8, T9, T10; local morselized bone graft, and demineralized bone matrix.”

The coding for this situation, as well as the 2008 RVUs and the percentage reimbursement that could be expected, is shown in Table 1. Note that it would be acceptable to report 22844 following the second 22216 because Current Procedural Terminology (CPT) includes posterior osteotomy CPT codes in the allowable primary codes for this add-on code. Additionally, some payors may require modifier 59 to indicate separate additional levels on the osteotomy codes; others will require modifier 76. If the osteotomy code is used as an add-on code, no modifier should be required.

Case 2: Posterior fusion with pelvic fixation
The orthopaedic surgeon performs a posterior fusion (T2-S1) with pelvic instrumentation to the ilium on a 13-year-old girl with a progressive double curve. The operative note indicates the following procedures:

“Posterior spinal fusion with segmental posterior instrumentation of levels T2 to the sacrum; instrumentation to the ilium with bilateral screw placement; local morselized autograft and allograft in lateral gutters.”

Table 2 shows the coding for this case.

Case 3: Posterior fusion with segmental instrumentation
The orthopaedic surgeon performs a posterior fusion on a 12-year-old girl who has progressive scoliosis. The surgeon dictates the following operative note:

“Posterior fusion from T10-L3; posterior segmental instrumentation, T10-L3; local morselized autograft and bone allograft.”

Table 3 shows the coding for this case.

Case 4: Posterior fusion replacing instrumentation
The patient is an 8-year-old girl with progressive scoliosis who has had multiple surgeries, including use of a single growing rod. Her condition has worsened, and junctional kyphosis has developed. The surgeon must remove the previously placed instrumentation and insert new instrumentation.

The operative note dictated by the orthopaedic surgeon indicates the following:

“Posterior fusion, T6-L5; removal of instrumentation, T5-L5; posterior osteotomies at T6, T7, T8, T9, T10, T11, and T12; posterior instrumentation, T2-L5; morselized allograft and local autograft to fusion.”

Table 4 shows the coding for this case. Note that it would be acceptable to report 22844 following the second 22216, because CPT includes posterior osteotomy CPT codes in the allowable primary codes for this add-on code. Also note that some payors may require use of modifier 59 to indicate separate additional levels; other payors may require modifier 76. If 22844 is used as an add-on code, no modifier should be required.

Action steps
When coding for pediatric spine deformities, be sure to take the following action steps:

Determine if payors want modifiers on the add-on codes to indicate separate levels or interspaces.

Monitor payment on add-on instrumentation codes to ensure proper payment.

Monitor denials for add-on and instrumentation codes because the payor could not identify a primary procedure. Because the instrumentation and bone graft codes became add-on codes in 2008, some payors have required the instrumentation to follow the arthrodesis codes as noted in these examples.

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