Choosing the appropriate code to describe spinal surgery performed across spinal regions such as the thoracolumbar junction has been a frequent dilemma for coders. The Current Procedural Terminology specifies a hierarchy of codes that identify work on the spine in cervical, thoracic, lumbar and sacral regions, but there are no specific CPT codes to identify work at the junction of these regions; the exception is 63087-63091 for anterior thoracolumbar corpectomy to allow for the unique additional work of diaphragmatic dissection.
Frequent questions concerning the difficulty of coding work performed at junctional levels prompted the CPT Editorial Panel to request instructional guidelines from the specialty societies earlier this year. These guidelines are currently under review by the CPT advisers from neurosurgery and orthopedics. This Coding Corner will examine the current proper choice of codes to describe junctional level spinal surgery.
Discectomy Anterior cervical and thoracic discectomy codes each have unique additional-level codes. Since exposure of the C7-T1 disc space utilizes an anterior cervical approach, the primary code 63075 for anterior cervical discectomy most appropriately describes decompression at the C7-T1 disc space. If additional discectomies are performed in the cervical spine, the additional level cervical code 63076 would be used.
If additional discectomies are performed in both the cervical spine and thoracic spine, two primary codes, 63075 and 63077, currently would be required, with 63075 appended with the -51 multiple procedural services modifier. However, since the typical patient would be undergoing an extended anterior cervical approach, it would seem more appropriate to continue to use the additional level cervical code 63076 for work in the upper thoracic spine, but this is not currently possible because the CPT descriptor for 63076 is only linked to the anterior cervical discectomy code 63075. CPT advisers are considering submission of a proposal to change the CPT descriptor of 63076 to allow for additional levels of upper thoracic discectomy.
Corpectomy For an anterior corpectomy, the use of corpectomy codes 63081-63091 is straightforward. The thoracolumbar area also has specific codes (63087-63091), and additional-level codes are designated for each region. For a corpectomy performed in two spinal regions, two primary codes are chosen, one of which is be appended with the -51 modifier.
Laminectomy Although primary level posterior laminectomy codes have individual codes 63045-63047 for specific spinal regions, they share a single additional-level code, 63048. If performing a cervicothoracic laminectomy, the primary cervical code 63045 should be used followed by 63048 for each additional level, regardless of whether the procedure is performed in the cervical or thoracic spine. Similarly, a thoracolumbar laminectomy should be coded with a primary lumbar code 63047 followed by 63048 for each additional level, regardless of whether the procedure is performed in the thoracic or lumbar spine.
Arthrodesis Posterior arthrodesis codes (22600-22612) would be used in a similar manner, as these also share the same additional-level code 22614. However, a single posterior arthrodesis at the cervicothoracic junction should be described with 22600, whereas a single posterior thoracolumbar arthrodesis should be described with 22612.
Coding for anterior arthrodesis would follow the same pattern. Since a C7-T1 arthrodesis would be performed through an anterior cervical approach, this procedure typically would be described using 22554. Additional level anterior arthrodesis is described with 22585, regardless of the spinal region where it is performed. Likewise, a T12-L1 arthrodesis would be described using 22558. Although there are no anterior codes for thoracolumbar junctional arthrodesis, this procedure would typically be performed with a decompression, in which case the corpectomy codes would identify the additional work of diaphragmatic take-down.
Decompression Additional difficulties are encountered in posterior decompressions for nondegenerative conditions such as spinal neoplasms (63300-63308). Although CPT includes single codes for each spinal region, some diseases affect more than one spinal region. It is recommended that a single primary code is chosen based on where the majority of the work is performed. It would seem unreasonable to use only one primary code for a four-level C3-C7 laminectomy for excision of intraspinal pathology, but two primary codes for a two-level laminectomy involving C7-T1. In this latter circumstance, a single primary cervical code should be used. In the circumstance of laminectomies performed in more than one spinal region (more than two segments in both regions), two primary codes should be used, appending one with the -51 multiple procedural services modifier. The anterior decompression codes for nondegenerative conditions follow the same rules as the degenerative anterior decompression codes.
Explanatory language now under development by the neurosurgery and orthopedics CPT advisers should help physicians and coders manage the sometimes confusing area of coding at junctional levels.
Gregory J. Przybylski, MD, is professor and director of neurosurgery at JFK Medical Center in Edison, N.J. He is a member of the CMS Practicing Physicians Advisory Council and the AANS/CNS Coding and Reimbursement Committee, and he plans and instructs coding courses for the AANS and the North American Spine Society.