This is the second in a series of articles providing a high-level overview of code changes for 2012. It is not meant to be an all-inclusive introduction to either the code changes or the guideline changes being introduced in 2012.

Last month’s column (“CPT Code Update 2012—Part 1, AAOS Now, January 2012) reviewed coding changes for Modifier 33, evaluation and management (E & M) guidelines, the skin replacement surgery section, wound repair guidelines, new CPT codes for the treatment of Dupuytren’s contracture, and updates to the arthroscopy section. This month’s column will focus on changes to spine coding.

Spine coding is undergoing multiple changes this year, including the addition of new codes for posterior spinal fusion, guideline changes, updates to the diskectomy codes, and new add-on codes.

Combination codes for spinal fusion
CPT has introduced two new codes to describe the surgeon’s work associated with performing a posterior interbody fusion and a posterolateral interbody fusion (PLIF) at the same level(s) during the same operative session. CPT code 22633 is defined as “Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and level; lumbar.” CPT code 22634 should be reported for each additional interspace.

The combined codes were created because Medicare identified that CPT codes 22612 and 22630 were reported together more than 75 percent of the time, which is the threshold for establishing a new code for reporting combined procedures performed during the same session.

For example, if a surgeon performs a posterolateral fusion and posterior interbody fusion at L3 through L5, the fusion would now be reported as follows:

• 22633 (L3-L4 combined posterolateral/posterior interbody fusion)
• 22634 (L4-L5 combined posterolater/posterior interbody fusion)

In addition, instrumentation and bone graft codes are separately reportable as appropriate.

If the surgeon performs a posterolateral fusion from L3 through L5, but does not perform a posterior interbody fusion, the traditional posterior lumbar fusion codes (22612 for the first level and 22614 for each additional level) should be used. Similarly, the surgeon continues to report 22630 if only a posterior lumbar interbody fusion at L4-L5 is performed.

According to the instructional guidelines, the combination code should be reported only when the two procedures are performed at the same levels. If an extended posterolateral fusion is performed in isolation, the instructions provide guidelines on how to report the case using add-on codes.

For example, the surgeon performs a combined posterior/interbody lumbar fusion at L4-L5 and a posterior fusion without interbody fusion at both L3-L4 and L5-S1. Reporting should be as follows:

• 22633 (combined posterior/interbody lumbar fusion L4-L5)
• 22614 (add-on posterior fusion L3-L4)
• 22614 (add-on posterior fusion L5-S1)

For payers other than Medicare, surgeons should refer to the specific payer’s rules for submitting the add-on codes. Some payers may want units, some may want a modifier on the second 22614, and some may accept the Medicare reporting.

Guideline changes
Guideline changes to CPT codes 22552 and 22525 (Vertebral body, embolization or injection) now mean that CPT codes 22520–22522 should not be reported in conjunction with CPT codes 20225, 22310–22315, 22325, or 22327 when performed at the same level.

Guideline changes also address removal of instrumentation and insertion of new instrumentation, including all or part of the previously instrumented segments as well as reinsertion at the same level. In years past, the surgeon reported the removal of old hardware (22850, 22852, 22855) and also reported the placement of new hardware when the procedures were performed at different levels.

Beginning in 2012, if a surgeon removes instrumentation at L3-L4 and inserts new instrumentation from L1 through L5, only the new instrumentation codes should be reported—not codes for both the removal of the old instrumentation and the insertion of new instrumentation. If the surgeon removes old instrumentation at L3-L4 and reinserts new instrumentation at the same level, the reinsertion code (22849) should be used.

Diskectomy Update
CPT codes 63020, 63030, and 63035 were revised to remove the phrase “including open and endoscopically-assisted approaches” from the code descriptors. The work associated with these codes requires open and direct visualization of the surgical field. If the visualization is only endoscopic or with image guidance, do not use CPT codes 63020, 63030, or 63035.

CPT codes 0274T and 0275T were released in January 2011, became effective in July 2011, and are listed as new Category III codes in 2012. Category III codes 0274T and 0275T describe “laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, with or without ligamentous resection, discectomy, facetectomy or foraminotomy using indirect guidance such as CT or fluoroscopic guidance, with or (computed tomography) without the use of an endoscope.”

CPT code 62287 was revised to read as follows: “Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar.” CPT code 62287 may include the use of an endoscope.

Infusion Pumps
The code description for 62367 was revised, and new codes were introduced for the reprogramming and refilling of implanted pumps for intrathecal or epidural drug infusions. If the procedures require the skill of a physician, use CPT code 62370; if a physician is not required, CPT code 62369 should be reported.

Injections
Guideline changes reinforce that diagnostic/therapeutic injections are not separately reportable with codes 64600–64681 because other therapeutic injections (such as corticosteroids) are inclusive to this code range.

CPT codes 64622–64627 have been deleted and replaced with CPT codes 64633–64636. CPT code 64633 describes injections of the cervical or thoracic joint; 64634 is the add-on code for each additional cervical or thoracic facet joint. CPT code 64635 describes a single lumbar or facet joint; 64636 represents the add-on code for each additional lumbar or sacral facet joint injection. Report an unlisted code, 64999, if the injections are performed without fluoroscopic or CT guidance.

Same-session EMG and NCS
Three new add-on codes (95885, 95886, and 95887) have been introduced to describe electromyography (EMG) services performed on the same day as nerve conduction studies (NCS). The stand-alone EMG codes can be reported when only the EMG study is performed; refer to the Guidelines section. They cannot be used if the EMG study is performed on the same day as the NCS.

Remember, these services have both a professional and a technical component and require a professional interpretation by the physician and a separate report. A computer report alone does not meet the professional interpretation component.

Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc. This article has been reviewed and approved by members of the AAOS Coding, Coverage, and Reimbursement Committee.