CPT® Coding Examples for Common Spine ... - Zimmer …

1 This list presents Current Procedural Terminology (CPT ) Coding Examples for Common Spine procedures. CERVICALA nterior Cervical Discectomy with Interbody Fusion (ACDF)Procedure DescriptionCodeModifierCommentsAnterior interbody fusion, with discectomy and decompression; cervical below C2cervical below C2, each additional interspace2 2 551225521st interspaceapply 59 modifier for 3+ interspace(s)Insertion of interbody biomechanical device ( , cages)To intervertebral disc space in conjunction with interbody fusion2285322853591st interspace, if applicableeach additional interspaceAnterior instrumentation (select applicable code)(Do not report when anterior instrumentation is considered integral to an interbody device and for the purpose of device anchoring ( , screws, flanges)2284522846228472-3 vertebral segments4-7 vertebral segments8+ vertebral segmentsApplication of bone graft (select applicable code)Allograft, morselized, or placement of osteopromotive materialAllograft, structuralAutograft, localAutograft, morselizedAutograft, structural2093020 931209362093720938 Anterior Cervical Fusion without DecompressionProcedure DescriptionCodeModifierCommentsArthrodes is, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression).)

2 Cervical below C2each additional interspace22554225851st interspaceapply 59 modifier for 3+ interspace(s)Insertion of interbody biomechanical device ( , cages)To intervertebral disc space in conjunction with interbody fusion2285322853591st interspace, if applicableeach additional interspaceAnterior instrumentation (select applicable code)(Do not report when anterior instrumentation is considered integral to an interbody device and for the purpose of device anchoring ( , screws, flanges)2284522846228472-3 vertebral segments4-7 vertebral segments8+ vertebral segmentsApplication of bone graft (select applicable code)Allograft, morselized, or placement of osteopromotive materialAllograft, structuralAutograft, localAutograft, morselizedAutograft, structural2093020 931209362093720938 Cervical Arthroplasty/Cervical Disc ReplacementProcedure DescriptionCodeModifierCommentsTotal disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervicalsecond level, cervical22856228581st interspace2nd interspaceCPT Coding Examples for Common Spine ProceduresPosterior Craniocervical FusionProcedure DescriptionCodeModifierCommentsArthrodes is, posterior technique, craniocervical (occiput-C2)22590 Occiput C2 Arthrodesis, posterior or posterolateral technique, single level;cervical below C2 segmenteach additional vertebral segment226002 2614511st segment below C2apply 59 modifier for 3+ vertebral segment(s) posterior instrumentation (select applicable code) posterior non-segmental instrumentationInternal spinal fixation by wiring of spinous processesPosterior segmental instrumentation; 3-6 vertebral segmentsPosterior segmental instrumentation; 7-12 vertebral segmentsPosterior segmental instrumentation.)

3 13 or more vertebral segments228402 2 8 412284222843228443 to 6 vertebral segments7 to 12 vertebral segments13+ vertebral segmentsApplication of bone graft (select applicable code)Allograft, morselized, or placement of osteopromotive materialAllograft, structuralAutograft, localAutograft, morselizedAutograft, structural2093020 931209362093720938 Cervical LaminoplastyProcedure DescriptionCodeModifierComments(select applicable code)Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments;with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed)63050630512 or more vertebral segmentsLUMBARA nterior Lumbar Interbody Fusion (ALIF)Procedure DescriptionCodeModifierCommentsArthrodes is, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbareach additional interspace22558225851st interspaceapply 59 modifier for 3+ interspace(s)Insertion of interbody biomechanical device ( , cages)to intervertebral disc space in conjunction with interbody fusion2285322853591st interspace, if applicableeach additional interspaceAnterior instrumentation (select applicable code)(Do not report when anterior instrumentation is considered integral to an interbody device and for the purpose of device anchoring ( , screws, flanges)2284522846228472-3 vertebral segments4-7 vertebral segments8+ vertebral segmentsApplication of bone graft (select applicable code)Allograft, morselized, or placement of osteopromotive materialAllograft, structuralAutograft, localAutograft, morselizedAutograft, structural2093020 931209362093720938 lateral Lumbar Interbody Fusion (LLIF) (aka.))

4 DLIF, XLIF, transpsoas interbody)Procedure DescriptionCodeModifierCommentsArthrodes is, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbareach additional interspace22558225851st interspaceapply 59 modifier for 3+ interspace(s)Insertion of interbody biomechanical device ( , cages)to intervertebral disc space in conjunction with interbody fusion2285322853591st interspace, if applicableeach additional interspaceAnterior instrumentation (select applicable code)(Do not report when anterior instrumentation is considered integral to an interbody device and for the purpose of device anchoring ( , screws, flanges)2284522846228472-3 vertebral segments4-7 vertebral segments8+ vertebral segmentsApplication of bone graft (select applicable code)Allograft, morselized, or placement of osteopromotive materialAllograft, structuralAutograft, localAutograft, morselizedAutograft, structural2093020 931209362093720938 ALIF/LLIF and Posterolateral FusionProcedure DescriptionCodeModifierCommentsArthrodes is, posterior or posterolateral technique, single level.

5 Lumbar (with lateral transverse technique, when performed)each additional vertebral segment2 26122 26141st interspaceapply 59 modifier for 3+ vertebral segment(s)Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbareach additional interspace2255822585511st interspaceapply 59 modifier for 3+ interspace(s) Insertion of interbody biomechanical device ( , cages)to intervertebral disc space in conjunction with interbody fusion2285322853591st interspace, if applicableeach additional interspacePosterior instrumentation (select applicable code) posterior non-segmental instrumentationInternal spinal fixation by wiring of spinous processesPosterior segmental instrumentation; 3-6 vertebral segmentsPosterior segmental instrumentation; 7-12 vertebral segmentsPosterior segmental instrumentation; 13 or more vertebral segments228402 2 8 412284222843228443 to 6 vertebral segments7 to 12 vertebral segments13+ vertebral segmentsApplication of bone graft (select applicable code)Allograft, morselized, or placement of osteopromotive materialAllograft, structuralAutograft, localAutograft, morselizedAutograft, structural2093020 931209362093720938 Posterolateral Fusion (PLF) with posterior InstrumentationProcedure DescriptionCodeModifierCommentsArthrodes is, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)each additional vertebral segment2 26122 26141st interspaceapply 59 modifier for 3+ vertebral segment(s) posterior instrumentation (select applicable code) posterior non-segmental instrumentationInternal spinal fixation by wiring of spinous processesPosterior segmental instrumentation; 3-6 vertebral segmentsPosterior segmental instrumentation.

6 7-12 vertebral segmentsPosterior segmental instrumentation; 13 or more vertebral segments228402 2 8 412284222843228443 to 6 vertebral segments7 to 12 vertebral segments13+ vertebral segmentsApplication of bone graft (select applicable code)Allograft, morselized, or placement of osteopromotive materialAllograft, structuralAutograft, localAutograft, morselizedAutograft, structural2093020 931209362093720938 posterior Lumbar Interbody Fusion (PLIF)/Transforaminal Lumbar Interbody Fusion (TLIF) with posterior InstrumentationProcedure DescriptionCodeModifierCommentsArthrodes is, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbareach additional interspace 22630226321st interspaceapply 59 modifier for 3+ interspace(s)Report applicable code if decompression is performed:Laminotomy (hemilaminectomy), with decompression of nerve root(s);1 interspace, lumbar each additional interspaceLaminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], single vertebral segment; lumbareach additional segment 6303063035630476304851, 5951, 591st interspaceapply 59 modifier for 3+ interspace(s)1st vertebral segmentapply 59 modifier for 3+ vertebral segment(s)Insertion of interbody biomechanical device ( , cages)to intervertebral disc space in conjunction with interbody fusion2285322853591st interspace, if applicableeach additional interspacePosterior instrumentation (select applicable code) posterior non-segmental instrumentationInternal spinal fixation by wiring of spinous processesPosterior segmental instrumentation; 3-6 vertebral segmentsPosterior segmental instrumentation; 7-12 vertebral segmentsPosterior segmental instrumentation.)

7 13 or more vertebral segments228402 2 8 412284222843228443 to 6 vertebral segments7 to 12 vertebral segments13+ vertebral segmentsApplication of bone graft (select applicable code)Allograft, morselized, or placement of osteopromotive materialAllograft, structuralAutograft, localAutograft, morselizedAutograft, structural2093020 931209362093720938 NOTE: CPT codes 63030 and 63047 are bundled per National Correct Coding Initiative (NCCI) edits with code 22630. CPT Assistant ( January 2001, page 12) states that these codes can be reported in addition to the fusion code if performed for decompression (apply modifier -59 to the decompression code).PLIF/TLIF with Posterolateral Fusion and InstrumentationProcedure DescriptionCodeModifierCommentsArthrodes is, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbareach additional interspace and segment22633226341st interspace and segmentapply 59 modifier for 3+ interspace(s) and segments(s)Report applicable code if decompression is performed:Laminotomy (hemilaminectomy), with decompression of nerve root(s);1 interspace, lumbar each additional interspaceLaminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], single vertebral segment.)

8 Lumbareach additional segment 6303063035630476304851, 5951, 591st interspaceapply 59 modifier for 3+ interspace(s)1st vertebral segmentapply 59 modifier for 3+ vertebral segment(s)Insertion of interbody biomechanical device ( , cages)to intervertebral disc space in conjunction with interbody fusion2285322853591st interspace, if applicableeach additional interspacePosterior instrumentation (select applicable code) posterior non-segmental instrumentationInternal spinal fixation by wiring of spinous processesPosterior segmental instrumentation; 3-6 vertebral segmentsPosterior segmental instrumentation; 7-12 vertebral segmentsPosterior segmental instrumentation; 13 or more vertebral segments228402 2 8 412284222843228443 to 6 vertebral segments7 to 12 vertebral segments13+ vertebral segmentsApplication of bone graft (select applicable code)Allograft, morselized, or placement of osteopromotive materialAllograft, structuralAutograft, localAutograft, morselizedAutograft, structural2093020 931209362093720938 NOTE: CPT codes 63030 and 63047 are bundled per National Correct Coding Initiative (NCCI) edits with code 22633.

9 CPT Assistant ( January 2001, page 12) states that these codes can be reported in addition to the fusion code if performed for decompression (apply modifier -59 to the decompression code).Discectomy, LumbarProcedure DescriptionCodeModifierCommentsLaminotom y (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbareach additional interspace 63030630351st interspaceapply 59 modifier for 3+ interspace(s) NOTE: If procedure is performed bilaterally, report modifier , LumbarProcedure DescriptionCodeModifierCommentsLaminecto my with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesismore than 2 vertebral segments; lumbar 630056 3 0171st or 2nd vertebral segmentsmore than 2 vertebral segmentsLaminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)6 3 012 Gill type procedureLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbareach additional interspace63030630351st interspaceapply 59 modifier for 3+ interspace(s) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace.

10 Lumbareach additional lumbar interspace63042630441st interspaceapply 59 modifier for 3+ interspace(s) Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], single vertebral segment; lumbareach additional segment63047630481st vertebral segmentapply 59 modifier for 3+ vertebral segment(s)Interlaminar/Interspinous Process Device InsertionProcedure DescriptionCodeModifierCommentsInsertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single levelsecond levelInsertion of interlaminar/interspinous process stabilization/distra)