Radiograph of a thoracic lumbar spine with thoracolumbar scoliosis.

AAOS Now

Published 12/20/2023
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Kevin M. Neal, MD, MBA

Coding for Vertebral Body Tethering for Treatment of Adolescent Idiopathic Scoliosis

Vertebral body tethering (VBT) was developed to treat adolescent idiopathic scoliosis (AIS) without spinal fusion. This procedure is accomplished by anchoring a flexible polyethylene cord on the lateral sides of the vertebral bodies on the convex side of the curve. The cord is anchored with vertebral body screws.

When performed in the thoracic spine, the procedure is often done thoracoscopically. In the lumbar and thoracolumbar regions, an open retroperitoneal approach to the anterior spine may be required. Curve correction is partially accomplished immediately by tensioning the cord across the apex of the curve, which also limits longitudinal growth on the convex side of the curve. Further correction may be gained postoperatively by continued growth of the vertebral bodies on the concave side of the curve.

The first device available in the United States for VBT was approved by the FDA under a humanitarian device exemption in 2019. Prior to that approval, screw and cord systems that were developed for use in adult lumbar spine surgery were used in an off-label manner.

Category III (temporary) Current Procedural Terminology (CPT) codes for this procedure were approved by the American Medical Association’s (AMA’s) CPT Editorial Committee in 2020. The Category III codes used for VBT were revised for 2024 and are listed below (see section “Revised/new Category III codes”). A vertebral segment, as defined in the CPT manual, includes the complete bony elements of a vertebra but does not include the interval disks between vertebrae. In this case, the number of vertebral segments corresponds to the number of vertebral bodies instrumented anteriorly.

Category III codes are temporary codes that are used for emerging technologies. They are typically for newer procedures that do not yet meet the criteria for Category I codes. Having a Category III code allows a procedure’s frequency to be tracked over time to assess the volume of procedures performed nationally. Category III codes are temporary and will “sunset” within five years unless specifically renewed through the CPT process. Category III codes have no assigned relative value units (RVUs), so reimbursement must be negotiated with payers on a case-by-case basis. Because Category III codes are currently available for VBT, it would be incorrect coding to use the unlisted spine code (22899).

Category I codes are assigned to common, established procedures. Each has an assigned RVU, which is typically used as the basis for reimbursement from both the Centers for Medicare & Medicaid Services and private payers. Category I codes require literature support with appropriate levels of evidence, and at the time of application, sufficient literature was only available to support Category I codes for thoracic VBT. The new codes have recently gone through the valuation process with the AMA’s Relative Value Scale Update Committee, and they will be available on Jan. 1, 2024. Until then, the existing Category III codes should be used to report these services.

New Category I codes
In 2022, AAOS, along with supporting subspecialty societies, submitted a code-change application to the AMA for Category I codes for VBT. Two new Category I codes for thoracic VBT and one new code for revision of a thoracic VBT were approved for reporting these services beginning Jan. 1, 2024. Typically, there is a co-surgeon to provide thoracoscopic access, and both surgeons would report the appropriate code with a 62 modifier.

The new Category I codes are:

  • 22836, Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; up to 7 vertebral segments (For anterior lumbar or thoracolumbar vertebral body tethering, up to 7 vertebral segments, use 0656T.)
  • 22837, Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; 8 or more vertebral segments (For anterior lumbar or thoracolumbar vertebral body tethering, 8 or more vertebral segments, use 0657T.) (Do not report codes 22836 or 22837 in conjunction with codes 22845, 22846, 22847, 32601.) (For anterior lumbar or thoracolumbar vertebral body tethering, 8 or more vertebral segments, use 0657T.)
  • 22838, Revision (eg, augmentation, division of tether), replacement or removal of thoracic vertebral body tethering, including thoracoscopy, when performed (Do not report code 22838 in conjunction with codes 22849, 22855, 32601.)

Revised/new Category III codes
At the same time, edits to the existing Category III codes were approved to specify lumbar/thoracolumbar VBT, and one new Category III code was added for lumbar/thoracolumbar VBT revision. The revised codes are:

  • 0656T, Anterior lumbar or thoracolumbar vertebral body tethering; up to 7 vertebral segments
  • 0657T, Anterior lumbar or thoracolumbar vertebral body tethering; 8 or more vertebral segments

The new Category III code is 0790T, Revision (e.g., augmentation, division of tether), replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy, when performed.

With the addition of new 2024 Category I codes for thoracic VBT and the new/revised Category III codes for lumbar/thoracolumbar VBT, these procedures can now be accurately reported and tracked.

Kevin M. Neal, MD, MBA, is a member of the AAOS Coding Coverage and Reimbursement Committee, represents the Pediatric Orthopaedic Society of North America, and is a pediatric spine surgeon in Jacksonville, Fla.