It seems like coding spine cases is as complicated as doing the surgery. Coders must have in-depth knowledge of the primary procedures and additional procedures along with affected areas to code appropriately for spine surgery billing. In this article, we shared basic principles of spine surgery billing which can use as a reference while billing for spine procedures.
For spine surgery billing purposes, the surgeon must select the most complex surgery being performed as the primary surgery. If the surgeon is planning a single-level lumbar spine fusion with decompression, the surgeon will select the single-level fusion procedure. The surgeon does not need to request separate authorization for the decompression procedure being performed as part of the lumbar fusion surgery. This is included in the lumbar fusion request. Or if a surgeon is planning a laminectomy with a microdiscectomy, the surgeon will select the lumbar decompression procedure. The surgeon does not need to request separate authorization for the microdiscectomy procedure.
Decompression is the general term to describe the removal of the spinal disk, bone, or tissue causing pressure and pain. Often, this is the only procedure performed. For spine surgery billing purposes, identify which decompression/discectomy activity the surgeon performed. Then, choose an appropriate standalone code and any associated add-on codes for the decompression. Note that, corpectomy (removal of part or all of a vertebral body) codes include the discectomy at the level above and below the corpectomy. Discectomy is a single, standalone code, such as 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of the herniated intervertebral disc; 1 interspace, lumbar. While decompression of the spinal canal can be coded per vertebral segment, or per level of foraminotomy.
Arthrodesis is the fusion, or permanent joining, of a joint, or point of union of two musculoskeletal structures, such as two bones. If the fusion (arthrodesis) is performed then choose the standalone CPT® code for the fusion (i.e., arthrodesis / the joining of two or more vertebrae). Fusion is the merging of adjacent parts; therefore, coding a single fusion segment involves two adjacent vertebral segments. Differentiate whether the approach was posterior or anterior to choose the correct arthrodesis code(s). The standalone code covers the first segment of fusion, and the associated add-on codes are used for additional levels of fusion.
As a fusion is performed, you must include a bone graft code. As with other graft codes in CPT®, the spinal bone graft codes are reported for harvesting the bone graft. The work of placing the bone graft is included in the arthrodesis/fusion codes. All spinal bone graft codes are add-on codes. CPT® guidelines allow for reporting each bone graft code once per operative session. From the operative note, determine whether the bone graft was an allograft or an autograft and whether it was a morselized (bits or pieces) or structural (wedge or chunk) bone. It helps to know what the bone type documented in the operative note looks like.
If the instrumentation is used in the fusion then choose the appropriate add-on code(s) for the instrumentation, also known as hardware. Review the operative note to determine where the instrument was used, and whether it was non-segmental, segmental, or intervertebral. Posterior instrumentation is categorized as non-segmental or segmental. Choose anterior instrumentation codes based on the number of vertebral segments the hardware (typically, a plate) spans. The instrumentation (medical device), bone grafts, and bone marrow aspiration are procedures commonly performed in conjunction with single or multiple-level lumbar or cervical spines.
If the other procedures are performed in addition to decompression then code for these other procedures.
With the above-mentioned guidelines, you can capture charges for spine procedures correctly with errors. Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services.