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The Business of Spine | Coding Handbook

The Business of Spine

Coding Handbook For Spine Surgery

2015

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The following Coding Concept Resource is not to be considered a replacement for the Current Procedural Terminology (CPT) book or the International Classification of Diseases 9th Revision-Clinical Modification (ICD-9-CM) book. It is designed simply as a resource to help you get a handle on it. Always refer back to the full Current Procedural Terminology (CPT) book when coding. Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listing are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. International Classification of Diseases 9th Revision-Clinical Modification (ICD-9-CM) is copyright 2014 OptumCoding. All Rights Reserved.

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Table of Contents Procedural Codes

DECOMPRESSION CODES ...................................................................................................................................................................... Anterior Decompression ................................................................................................................................................................... Discectomy ....................................................................................................................................................................................... Transoral Approach…………………………………………………………………………………………………………….. Corpectomy ...................................................................................................................................................................................... Corpectomy for Lesion ..................................................................................................................................................................... Posterior Decompression .................................................................................................................................................................. Laminotomy/Discectomy ................................................................................................................................................................. Laminoplasty .................................................................................................................................................................................... Laminectomy .................................................................................................................................................................................... Laminectomy for Excision of Lesion other than Herniated Disk..................................................................................................... Extracavitary Decompression ........................................................................................................................................................... Lateral Extracavitary Approach for Extradural Exploration/Decompression ..................................................................................

DURAL REPAIR………………………………. ........................................................................................................................................ ARTHROPLASTY..................................................................................................................................................................................... FUSION CODES ..........................................................................................................................................................................................

Anterior Fusion ................................................................................................................................................................................. Posterior Fusion ................................................................................................................................................................................ Extracavitary Fusion ......................................................................................................................................................................... Exploration of Fusion ........................................................................................................................................................................ Pre-Sacral Fusion .............................................................................................................................................................................. Instrumentation ................................................................................................................................................................................. Anterior ............................................................................................................................................................................................ Posterior ............................................................................................................................................................................................ Interbody Implants (Anterior or Posterior)....................................................................................................................................... Removal/Reinsertion (Anterior or Posterior) ................................................................................................................................... Bone Grafts ....................................................................................................................................................................................... Bone Marrow Aspiration ................................................................................................................................................................. SPINAL DEFORMITY .................................................................................................................................................................... Intraspinous/Intrafacet Procedures ....................................................................................................................................................

OSTEOTOMY/EXCISION OF BONE ........................................................................................................................................................ Excision ................................................................................................................................................................................................. Osteotomy ..............................................................................................................................................................................................

MISCELLANEOUS CODES....................................................................................................................................................................... Fracture................................................................................................................................................................................................. Tongs/Halo............................................................................................................................................................................................ Vertebroplasty....................................................................................................................................................................................... Kyphoplasty…....................................................................................................................................................................................... Annuloplasty......................................................................................................................................................................................... Incision & Drainage…......................................................................................................................................................................... Infection…............................................................................................................................................................................................ Biopsy………....................................................................................................................................................................................... Neurostimulators……………................................................................................................................................................................ Bone Growth Stimulators….................................................................................................................................................................. Imaging…….......................................................................................................................................................................................... Unspecified Procedure Code.................................................................................................................................................................

Appendix A: Modifiers Appendix B: Category III Codes: T Codes Appendix C: Diagnosis Codes Appendix D: Terminology

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Procedural Codes DECOMPRESSION CODES Anterior Decompression Discectomy 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including

osteophytectomy; cervical, single interspace (Do not report 63075 in conjunction with 22554, even if performed by separate providers. To report anterior cervical discectomy and interbody fusion at the same level during the same session use 22551.)

+63076 Cervical, each additional interspace (Do not report 63076 in conjunction with 22554, even if performed by separate providers. To report anterior cervical discectomy and interbody fusion at the same level during the same session use 22552.)Use 63076 in conjunction with 63075

63077 Discectomy, anterior, thoracic, single interspace

+63078 Thoracic, each additional interspace.

Transoral Approach 61575 Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or

excision of lesion

61576 Requiring splitting of tongue and/or mandible (including tracheostomy)

Corpectomy for Spinal Condition 63081 Vertebral corpectomy (vertebral body resection), cervical, single segment. Partial or

complete corpectomy, with decompression of spinal cord and/or nerve root(s) +63082 Cervical, each additional segment

63085 Vertebral corpectomy (vertebral body resection), thoracic, single segment

+63086 Thoracic, each additional segment

63087 Vertebral corpectomy (vertebral body resection), thoracolumbar approach, lower thoracic or lumbar, single segment

+63088 Each additional segment

63090 Vertebral corpectomy (vertebral body resection), transperitoneal or retroperitoneal approach, lower thoracic, lumbar or sacral, single segment


Corpectomy for Intraspinal Lesion 63300 Vertebral corpectomy (vertebral body resection), extradural, cervical, single segment. Partial

or complete corpectomy for excision of intraspinal lesion

63301 Extradural, thoracic, by transthoracic approach, single segment

63302 Extradural, thoracic, by thoracolumbar approach, single segment

63303 Extradural, lumbar or sacral by transperitoneal or retroperitoneal approach, single segment


63304 Vertebral corpectomy (vertebral body resection), intradural, cervical, single segment

63305 Intradural, thoracic by transthoracic approach, single segment

63306 Intradural, thoracic by thoracolumbar approach, single segment

63307 +63308

Intradural, lumbar or sacral by transperitoneal or retroperitoneal approach, single segment Each additional segment

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Posterior Decompression Laminotomy/Discectomy 62287 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

63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical

63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

+63035 Each additional interspace, cervical or lumbar

0274T

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic

0275T Lumbar

63040 Laminotomy, (hemilaminectomy), re-exploration, cervical (unilateral), single interspace, with decompression of nerve root, including partial facetectomy, foraminotomy and/or discectomy

+63043 Each additional interspace, cervical

63042 Laminotomy, (hemilaminectomy), re-exploration, lumbar, (unilateral), one interspace.

+63044 Each additional interspace, lumbar

63055 Transpedicular approach, thoracic, single segment, with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc).

63056 Transpedicular lumbar, single segment, including transfacet or lateral extraforaminal approach. (e.g. herniated intervertebral disc)

+63057 Each additional segment, thoracic or lumbar

63064 Costovertebral approach, thoracic, single segment, with decompression of spinal cord or nerve root(s), (e.g., herniated intervertebral disk)


Laminoplasty 63050 Laminoplasty, cervical, two or more vertebral segments, with decompression of the spinal cord 63051 Laminoplasty, cervical, with reconstruction of the posterior bony elements, including the

application of bridging bone graft and non-segmental fixation devices (e.g., wire, suture, mini-plates), when performed

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Laminectomy 63001 Laminectomy, cervical, one or two vertebral segments, with exploration and/or decompression

of spinal cord and/or cauda equina, but without facetectomy, foraminotomy or discectomy, (spinal stenosis)

63003 Thoracic, one or two vertebral segments

63005 Lumbar, one or two vertebral segments, except for spondylolisthesis

63011 Sacral

63012 Laminectomy, lumbar (Gill type procedure), with removal of abnormal facets and/or pars

inter-articularis with decompression of cauda equina and nerve root for spondylolisthesis

63015 Laminectomy, cervical, more than two segments, with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (spinal stenosis)

63016 Thoracic, more than two segments

63017 Lumbar, more than two segments

63045 Laminectomy, cervical, single segment, including facetectomy and foraminotomy (unilateral or

bilateral) with decompression of spinal cord, cauda equina and/or nerve roots(s), (e.g., Spinal or lateral recess stenosis).

63046 Thoracic, single vertebral segment.

63047 Lumbar, single vertebral segment.

+63048 Each additional segment: cervical, thoracic or lumbar.

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Laminectomy for Excision of Lesion other than Herniated Disk 63250 Laminectomy, cervical, for excision of occlusion of arteriovenous malformation of spinal cord 63251 Thoracic 63252 Thoracolumbar 63265 Laminectomy, extradural, cervical, for excision or evacuation of intraspinal lesion other than

neoplasm 63266 Thoracic 63267 Lumbar 63268 Sacral 63270 Laminectomy, intradural, cervical, for excision of intraspinal lesion other than neoplasm 63271 Thoracic 63272 Lumbar 63273 Sacral 63275 Laminectomy, extradural, cervical, for biopsy/excision of intraspinal neoplasm 63276 Thoracic 63277 Lumbar 63278 Sacral 63280 Extramedullary, intradural, cervical 63281 Thoracic 63282 Lumbar 63283 Sacral 63285 Intramedullary, intradural, cervical 63286 Thoracic 63287 Thoracolumbar 63290 Combined extradural-intradural lesion, any level. + 63295 Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal

procedure

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Lateral Extracavitary Decompression Lateral Extracavitary Approach for Extradural Exploration/Decompression

63101 Vertebral corpectomy thoracic, lateral extracavitary approach, partial or complete corpectomy with decompression of spinal cord and/or nerve root(s) (e.g., for tumor or retropulsed bone fragments), single segment

63102 Lumbar, single segment

+63103 Thoracic or lumbar, each additional segment

Dural Repair

63707 63709 63710

Repair of dural/celebrospinal fluid leak, not requiring laminectomy With laminectomy Dural graft, spinal

Arthroplasty-Artificial Disc 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate

preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); cervical, single interspace

+22858

Second level; cervical

+0375T Cervical; three or more levels

22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace; lumbar, single interspace

+0163T each additional interspace, lumbar

22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach; cervical, single interspace

+0098T

each additional interspace, cervical

22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach; lumbar, single interspace


22864 Removal of total disc arthroplasty (artificial disc), anterior approach; cervical, single interspace.

+0095T each additional interspace, cervical

22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar


0202T Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine

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FUSION CODES Anterior Fusion 22548 Arthrodesis, C1-C2 (atlas-axis), anterior transoral or extraoral technique, with or without

excision of odontoid process

22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2

+22552 cervical below C2, each additional interspace

22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2

22556 Thoracic

22558 Lumbar

+22585 Each additional interspace

Posterior Fusion 22590 Arthrodesis, craniocervical, posterior technique

22595 Arthrodesis, C1-C2, posterior

22600 Arthrodesis, cervical below C2, posterior or posterolateral, single level

22610 Thoracic, with lateral transverse technique, when performed

22612 Lumbar, with lateral transverse technique, when performed

+22614 Each additional vertebral segment

22630

Arthrodesis, lumbar, posterior interbody technique, single interspace, including laminectomy and/or discectomy to prepare interspace (other than for decompression)

+22632 Each additional interspace

22633

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy (other than for decompression), single interspace, and segment; lumbar

+22634 Each additional interspace and segment, lumbar

Lateral Extracavitary Fusion 22532 Arthrodesis, thoracic, lateral extracavitary technique, including minimal discectomy to

prepare interspace (other than for decompression).

22533 Lumbar

+22534 Thoracic or lumbar, each additional vertebral segment

Exploration of Fusion 22830 Exploration of spinal fusion

Pre-Sacral Fusion 22586 Pre-sacral interbody fusion with posterior instrumentation, L5-S1 interspace +0309T L4-L5 interspace 0195T Pre-sacral interbody fusion, without instrumentation, L5-S1 interspace +0196T L4-L5 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive, with image guidance, includes

obtaining bone graft when performed and placement of transfixing device. 27280 Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation,

when performed.

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INSTRUMENTATION Anterior +22845 Anterior instrumentation, 2-3 vertebral segments +22846 4 to 7 vertebral segments +22847 8 or more vertebral segments

Posterior +22840 Posterior non-segmental instrumentation. (e.g., single Harrington rod technique, pedicle

fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation)

+22841 Internal fixation by wiring of spinous processes +22842 Posterior segmental instrumentation, 3 to 6 segments. (e.g., pedicle fixation, dual rods with

multiple hooks and sublaminar wires) +22843 7 to 12 vertebral segments +22844

+22848 13 or more vertebral segments Pelvic fixation other than sacrum

Interbody Implants (Anterior or Posterior) +22851 Application of intervertebral biomechanical device(s) (e.g., synthetic cages(s),

methylmethacrylate) to vertebral defect or interspace. (List separately in addition to code for primary procedure)

Removal/Reinsertion (Anterior or Posterior) 22849 Reinsertion of spinal fixation device 22850 Removal of posterior non-segmental instrumentation 22852 Removal of posterior segmental instrumentation; e.g. pedicle screws at several levels 22855 Removal of anterior instrumentation

Bone Grafts +20930 Allograft: morselized or placement of osteopromotive material, for spine surgery only (List

separately in addition to code for primary procedure) +20931 Allograft: structural, for spine surgery only (List separately in addition to code for primary

procedure) +20936 Autograft: (includes harvesting the graft); local (ribs, spinous process, or laminar fragments);

obtained from same incision +20937 Autograft: Morselized, through separate skin or fascial incision +20938 Autograft: Structural Bicortical or tricortical (through separate skin or fascial incision)

Bone Marrow Aspiration 38220 Bone marrow, aspiration only

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Spinal Deformity 22800 Arthrodesis, posterior for spinal deformity, up to 6 vertebral segments, with or without cast 22802 7 to 12 vertebral segments 22804 13 or more vertebral segments 22808 Arthrodesis, anterior for spinal deformity, 2 to 3 vertebral segments, with or without cast 22810 4 to 7 vertebral segments 22812 8 or more segments 22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segments(s)

(including body and posterior elements); single or 2 segments 22819 3 or more segments

Intraspinous/Intrafacet Procedures

0219T

Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices(s) single level; cervical

0220T Thoracic

0221T Lumbar

+0222T Each additional vertebral segment

0171T Insertion of posterior spinous process distraction device; lumbar; single level

+0172T

Each additional level

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OSTEOTOMY/EXCISION OF BONE Excision for Intrinsic Bony Lesion 22100 Partial excision of posterior vertebral component (e.g., spinous process, lamina or facet),

cervical, single vertebral segment 22101 Thoracic 22102 Lumbar +22103 Each additional segment 22110 Partial excision of vertebral body, cervical, single vertebral segment, without decompression of

spinal cord or nerve root(s) 22112 Thoracic 22114 Lumbar +22116 Each additional segment

Osteotomy 22206 Osteotomy of spine, posterior or posterolateral approach, three columns, (e.g., PSO)

thoracic, one vertebral segment 22207 Lumbar +22208 Each additional segment 22210 Osteotomy of spine, posterior or posterolateral approach, (e.g. Smith Peterson) cervical, one

vertebral segment 22212 Thoracic 22214 Lumbar +22216 Each additional segment

22220 Osteotomy of spine, including discectomy, anterior approach, (e.g. Smith Peterson) cervical,

single vertebral segment 22222 Thoracic 22224 Lumbar +22226 Each additional segment

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Miscellaneous Fracture 22305 Closed treatment of vertebral process fracture 22310 Closed treatment of vertebral body fracture w/o manipulation requiring casting or bracing 22315 Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing,

with and including casting and/or bracing by manipulation or traction 22318

22319

Open treatment and/or reduction of odontoid fracture(s) and/or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting With grafting

22325 22326 22327 +22328

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar Cervical Thoracic Each additional fractured vertebra or dislocated segment

Tongs/Halo

20660 20661

Application of cranial tongs, caliper or stereotactic frame, including removal Application of halo, including removal; cranial

Vertebroplasty: Vertebral Body, Embolization or Injection 22510 Percutaneous vertebroplasty (bone biopsy included when performed), one vertebral body,

unilateral or bilateral injection; inclusive of all imaging guidance; cervicothoracic 22511 lumbosacral

+22512 Each additional cervicothoracic or lumbosacral vertebral body

Kyphoplasty 22513

Percutaneous vertebral augmentation, including cavity creation using mechanical device, one vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

22514 lumbar

+22515 Each additional thoracic or lumbar vertebral body

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Annuloplasty 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral, including

fluoroscopic guidance; single level

+22527 One or more additional levels

Incision and Drainage 22010 Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical,

thoracic, or cervicothoracic 22015 lumbar, sacral, or lumbosacral

Infection 10180 Incision and drainage, complex, postoperative wound infection

Biopsy

20200 20205 20206

Biopsy, muscle; superficial deep percutaneous needle

20220 20225 20240 20245 20250 20251

Biopsy, bone, trocar, or needle: superficial (eg, spinous process, ribs, femur) deep (eg, vertebral body, femur) Biopsy bone, open; superficial (eg, ilium, sternum, spinous process,) deep (eg, humerus, ischium, vertebral body, femur) Biopsy, vertebral body, open; thoracic cervical or lumbar

Neurostimulators

63650 63655

Percutaneous implantation of neurostimulator electrode array, epidural Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

63661

63662

63663 63664 63685

63688

Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

Revision, including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Revision including replacement of spinal neurostimulator electrode plate/paddles(s) placed via laminotomy or laminectomy, including fluoroscopy

Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling

Revision or removal of implanted spinal neurostimulator pulse generator or receiver

0282T

Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous, cervical, thoracic or lumbar, for trial, including removal at the conclusion of trial period

0283T Permanent, implantation of neurostimulator with implantation of a pulse generator

0284T

Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed

0285T

Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed

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Bone Growth Stimulators 20974

20975 20680

Electric stimulation to aide in bone healing; Non Invasive Invasive (operative) Removal of implant, deep (e.g., buried wire, pin screw, metal band and, nail, rod or plate)

Imaging

69990 76000 61783

Microsurgical techniques, requiring use of operating microscope Fluoroscope; up to 1 hour physician time Stereotactics

Unspecified Procedure Codes 64999

22899

Unlisted procedure, nervous system Unlisted procedure, spine

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Appendix A: Modifiers 22 Increased Procedural Services: When the service(s) provided is greater than that usually provided for the listed procedure, it may be identified by adding a modifier 22 to the usual procedure code. A report may also be appropriate. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding a modifier 50 to the appropriate code. 51 Multiple Procedures: When multiple procedures, other than E/M services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). 52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced. 53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. 59 Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. 62 Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. 80/82 Assistant Surgeons: Surgical assistant services may be identified by adding modifier 80 or 82 to the usual procedure number(s). Use 82 modifier if a residency program is in place or 80 modifier if there is no residency program in place.

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Appendix B: Category III Codes: T-Codes

+0095T

Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace; cervical. (List separately in addition to code for primary procedure)

+0098T

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace; cervical

+0163T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar.

+0164T

Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar.

+0165T

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace; lumbar.

0171T

Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level

+0172T each additional level.

0195T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed: L5-S1 interspace

0196T L4-L5 interspace

0200T

Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles

0201T

Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles

0202T

Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine

0219T

Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices(s) single level; cervical

0220T thoracic

0221T lumbar

+0222T

each additional vertebral segment

0274T

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic

0275T lumbar 0282T

Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period

0283T permanent, with implantation of a pulse generator

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0284T

Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed

0285T

Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed

+0309T

Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace

0375T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); cervical, 3 or more levels

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Appendix C: Diagnosis Codes Late Effects of Infectious and Parasitic Diseases 139.8 Late effects of other and unspecified infectious and parasitic diseases

Neoplasms 170.2

170.6 192.2 192.9

Malignant neoplasm of bone and articular cartilage; Vertebral column, excluding sacrum and coccyx Malignant neoplasm of bone and articular cartilage; sacrum and coccyx Malignant neoplasm of Spinal Cord Malignant neoplasm of other specified sites of the nervous system

198.4 198.5

Secondary malignant neoplasm of other parts of nervous system Secondary malignant neoplasm of bone and bone marrow

198.89 Secondary malignant neoplasm of other specified sites 213.2

213.6 Benign neoplasm of bone and articular cartilage; vertebral column, excluding sacrum and coccyx Benign neoplasm of bone and articular cartilage; pelvic bones, sacrum and coccyx

238.0 Neoplasm of uncertain behavior of bone and articular cartilage 238.8 Neoplasm of uncertain behavior of other specified sites 239.2 Neoplasms on unspecified nature; Bone soft tissue and skin 239.8 Neoplasms on unspecified nature; Other specified sites 239.9 Neoplasms on unspecified nature; Site unspecified

Instability 718.88 Instability, other joint derangement, not elsewhere classified, other specified sites NEC 719.90 Other and unspecified disorders of joint; site unspecified 724.6 Other and unspecified disorders of back; Instability, lumbosacral; disorders of the sacrum

Spondylosis 721.0 Cervical Spondylosis without Myelopathy 721.1 Cervical Spondylosis with Myelopathy 721.2 Thoracic Spondylosis without Myelopathy 721.3 Lumbar Spondylosis without Myelopathy 721.4 Thoracic or Lumbar Spondylosis with Myelopathy 721.41 Thoracic region 721.42 Lumbar region 721.90 Spondylosis of unspecified site, without mention of Myelopathy 721.91 Spondylosis of unspecified site, with mention of Myelopathy

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Displacement/Herniation 722.0 Displacement of cervical intervertebral disc without Myelopathy 722.10 Displacement of Lumbar intervertebral disc without Myelopathy 722.11 Displacement of Thoracic intervertebral disc without Myelopathy 722.2 Displacement of intervertebral disc, site unspecified without myelopathy 722.6 Degeneration of intervertebral disc, site unspecified 722.71 Intervertebral disc disorder with Myelopathy; cervical region 722.72 Intervertebral disc disorder with Myelopathy; thoracic region 722.73 Intervertebral disc disorder with Myelopathy; lumbar region

Degenerative/Degeneration 722.4 Degeneration of cervical intervertebral disc; degenerative disc disease 722.51 Degeneration of thoracic or thoracolumbar degenerative disc disease 722.52 Degeneration of lumbar or lumbosacral degenerative disc disease

Postlaminectomy Syndrome 722.81 Postlaminectomy syndrome, cervical region 722.82 Postlaminectomy syndrome, thoracic region 722.83 Postlaminectomy syndrome, lumbar region

Disc Disorder 722.91 Other and unspecified disc disorder; cervical region 722.92 Other and unspecified disc disorder; thoracic region 722.93 Other and unspecified disc disorder; lumbar region

Stenosis 723.0 Spinal Stenosis in cervical region 724.01 Spinal Stenosis in thoracic region 724.02 Spinal Stenosis in lumbar region

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Radiculitis/Radiculopathy 723.4 Brachial neuritis or radiculitis NOS, cervical 729.2 Neuralgia, neuritis, radiculitis, unspecified

Pain & Radiculitis 723.1 Cervicalgia; pain cervical spine 723.4 Brachial neuritis or radiculitis NOS 723.7 Ossification of posterior longitudinal ligament in cervical region 724.1 Pain in the thoracic spine 724.2 Lumbago; lumbar pain 724.3 Sciatica 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 724.5 Backache, unspecified 724.6 Disorders of sacrum 727.40 Synovial cyst, unspecified 728.5 Hypermobility syndrome 729.0 Rheumatism, unspecified and fibrositis 729.1 Myalgia and myositis, unspecified

Disorders 733.00 Osteoporosis 733.20 Cyst of bone (localized); unspecified

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Fractures 733.10 Pathologic fracture; unspecified site 733.13 Pathologic fracture of vertebrae 733.81 Malunion of fracture 733.82 Non-union of fracture; pseudoarthrosis 805.0 Fracture of vertebral column without mention of spinal cord injury, cervical level, unspecified

level 805.1 Cervical, open *** For 805.0 & 805.1, you must add the 5th digit which is the level at which the

fracture has been noted; for example, closed fracture at C4 = 805.04*** 805.2 Dorsal [Thoracic], closed 805.3 Dorsal [Thoracic], open 805.4 Lumbar, closed 805.5 Lumbar, open 805.6 Sacrum and coccyx, closed 805.7 Sacrum and coccyx, open 805.8

805.9 Unspecified, closed Unspecified, open

Kyphosis 737.0 Adolescent postural kyphosis 737.10 Kyphosis (acquired) (postural) 737.11 Kyphosis due to radiation 737.12 Kyphosis, postlaminectomy 737.19 Other 737.20 Lordosis (acquired) (postural)

Scoliosis 737.30 Scoliosis (and kyphoscoliosis), idiopathic 737.39 Other 737.40 Curvature of spine, unspecified 737.41 Kyphosis 737.8

737.9 Other curvatures of spine Unspecified curvature of spine

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Spondylolisthesis 738.4 Acquired Spondylolisthesis 756.11 Spondylolysis, lumbosacral region 756.12 Spondylolisthesis 756.13 Absence of vertebra, congenital

Sprain/Strain 846.0 Sprain/strain of lumbosacral 847.0 Sprain/strain of neck 847.1 Sprain/strain of thoracic 847.2 Sprain/strain of lumbar

Post-Op 996.4 Mechanical Complication of internal orthopedic device, implant, and graft 996.59 Mechanical complication of other specified prosthetic device, implant or graft due to other

implant and internal device, not elsewhere classified 996.67 Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft 998.32 Disruption of external operation wound 998.51 Infected postoperative seroma 998.59 Other postoperative infection 998.83 Non-healing surgical wound V45.4 Arthrodesis status V45.89 Post-surgical status, other

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Appendix D: Terminology A vertebral segment describes the basic constituent part into which the spine is divided. It represents a single complete vertebral bone with its associated articular processes and laminae. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies which contain the intervertebral disc and the nucleus pulposus, annulus fibrosus and two cartilagenous endplates. Segmental instrumentation is defined as fixation at each end of the construct and at least one additional interposed bony attachment. Non-segmental instrumentation is defined as fixation at each end of the construct and may span several vertebral segments without attachment of the intervening segments.

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