2 Top Tips for Spinal Surgery Coding

spinal surgery coding guidelines, lumbar surgery diagnosis code, back surgery diagnosis code

Consider 22 for Every Deserved Dollar of 2-Level HNP Repair

When a surgeon performs spinal surgery for treatment of herniated nucleus pulposus (HNP) at two levels, with one being recurrent at L5-S1 and the second a new HNP at the disk space of L4-L5, coding the procedure in CPT® is slightly more complicated than when coding a surgery at a single level.

In this two-level case, report treatment with reexploration of the recurrent, HNP at L5-S1 with 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploraton, single interspace; lumbar) because this is a reexploration procedure. Reexplorations can be more complicated because of possible adhesions and other postoperative complications from the previous HNP, so depending upon the extent of the surgeon’s documentation, you might be able to append modifier 22 (Increased procedural services) as well.

For the new HNP at L4-L5, report 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar). Make sure to include modifier 59 (Distinct procedural service) on 63042 to indicate procedures performed at different spinal levels.

Diagnosis coding: The ICD-9 Index entry for Herniation, nucleus pulposus says to see the entry for Displacement, intervertebral disc. In that entry, the code for lumbar and lumbosacral is 722.10 (Displacement of lumbar intervertebral disc without myelopathy). Your ICD-10 lumbar surgery diagnosis code options have a surprise for you, offering two cross codes for 722.10:

  • Lumbar:26, Other intervertebral disc displacement, lumbar region
  • Lumbosacral: 27, Other intervertebral disc displacement, lumbosacral region.

Go Unlisted for Spinal Hardware Injection Coding

When coding for hardware injection, which is when a provider injects a short-duration local anesthetic, such as lidocaine, around a vertebral screw on a patient who has had a past spinal fusion, the best code to report is 64999 (Unlisted procedure, nervous system), as there is no specific code for hardware injection.

The purpose of hardware injection is to determine if a retained vertebral screw is the source of the patient’s post fusion pain, perhaps due to the screw’s placement near a spinal nerve. This is a diagnostic procedure; if the patient reports relief of pain after injection of the anesthetic, at least until the medication wears off, then the provider knows that the retained screw is most likely the source of the pain. If you receive a denial to your claim for this service, appeal with a statement explaining why you’re using the unlisted code.

Stay tuned – We’ll have more spinal coding tips tomorrow!

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

1 Comments For This Post

  1. Jack Titchener Says:

    I never knew that they used lidocaine when working around the vertebral screw. I imagine they do this so that it is less painful for the patient during the injections. I learned a lot about back surgeries from your article so thank you!

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