Lynn Thornton RHIA, CCS
Spinal instrumentation maintains stability while facilitating fusion process. This procedure is meant to restore stability to the spine, correct deformity and bridge the space created by the removal of intervertebral discs.
Examples of spinal instrumentation include rods, hooks, braided cable, plates, bone screws, rods, and interbody devices.
- An interbody cage is a permanent prosthesis left in place to maintain the foraminal height and decompression following surgery.These are simply structures that support bones while new bone growth occurs through and around them.
- Pedicle screws help to hold the vertebral body in place until the fusion is complete.
- Plates help to conform and contour the spine. These are held in place by screws set into adjacent vertebrae.
Spinal Instrumentation CPT Codes
CPT coding for spinal fusions can be tricky, particularly when spinal instrumentation is used. In January of 2017, the CPT code 22851 for insertion of intervertebral biomechanical device was deleted from the CPT code set. This was replaced with three new codes:
- 22853 – Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)
- 22854 – Insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
- 22859 – Insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
Referenced Deleted Code: 22851 – Application of intervertebral biomechanical device[s] [eg, synthetic cage[s], methylmethacrylate] to vertebral defect or interspace [List separately in addition to code for primary procedure]
Which code should be reported?
The most common code used when coding for spinal instrumentation is 22853. This code may be used for spinal procedures where the approach is anterior or posterior procedures and is not limited to just anterior spine procedures only.
- Anterior Approach: The surgeon places the patient supine (lying face up) and accesses the spine through an incision in the front of the body.
- Posterior Approach: The surgeon gains access to the spine through an incision in the back with the patient prone or face down.
CPT states that 22853 includes the placement of any anterior integral instrumentation. This means that the anterior plate is necessary to use with the device (cage.) The plate/screw(s) are used to secure the cage to the fused vertebrae. The includes note listed with code 22853 is a distinction that was not made clear with the old code device code 22851. This resulted in incorrectly reported codes 22851 and 22845 Anterior instrumentation; 2 to 3 vertebral segments, when only 22851 was appropriate.
When an intervertebral device is placed with an integrated anterior plate it is also called a “low profile” or “stand-alone” device. This is accurately reported and billed using only CPT code 22853. It is incorrect to separately report (unbundle) 22845 if an integrated plate was used to secure the device into the interspace.
How will you know if the fusion device should be reported using only CPT code 22853 OR both 22853 and 22845?
The surgeon should document in the operative report whether he/she secured the cage/device with the instrumentation. If additional instrumentation is used that was not secured/anchored to the device then it would be appropriate to report additional instrumentation.
You can also look to see if the specific device used is documented in the operative report and research it online. Many manufacturers have reimbursement guides with coding/billing advice on their websites that give the correct code(s) that should be reported.
Here are some example of additional instrumentation that should be coded separately when inserted during a fusion:
- Insertion of inViZia® Anterior Cervical Plate System
- Insertion of PEEK cage for fusion of L1-L4 with additional plate inserted at L5-S1 for spinal stabilization
When would you use 22854?
CPT 22854 is used when an intervertebral device is placed into a corpectomy defect and an arthrodesis is then performed.
A C6 corpectomy is performed with discectomies at levels C5-C6 and C6-C7 with preparation of the C5 and C7 endplates. An expandable titanium cage packed with bone graft for arthrodesis is placed into the corpectomy defect, and a plate is secured to C5 and C7. The expandable titanium cage is reported using 22854 because it was placed in a corpectomy defect and arthrodesis was performed.