Thursday, April 14, 2011

Strategies to Ease Your Spinal Osteotomies

When your orthopedic surgeon carries out spinal osteotomies, you have a much better chance of achieving full reimbursements if the procedure note clearly defines the surgeon's intent and approach. Particularly, you should look cautiously for whether the doctor carried out decompression beyond the osteotomy and scrutinize the operative note for indications that a discectomy has been carried out.

Spinal osteotomy is carried out when fusion alone wouldn't make proper a spinal deformity like a change in anterior or lateral curvature of the spine. Osteotomies are indicated only when a corrective fusion isn't enough. If the degree of deformity is serious, only then is an osteotomy indicated.

When the operating surgeon removes a portion of the vertebral segment(s) using codes in the 22206 to 22226 range, go for spinal osteotomy.

Important: Spot on selection depends on three factors: a) the approach, b) the anatomical location of the procedure in the spine, and c) the number of vertebral segments operated upon. Remember that location refers to the area of the spine which is being worked on - which can be cervical (C1-C7), thoracic (T1-T12), lumbar (L1-L5) or sacral (S1-S4).

Find out the approach

Go through the notes to identify the patient's position (supine or prone) to get started. When doctors add information about the approach to the operative report, ‘this helps the coder to choose the proper code to be billed.

Report code 22206, 22207 or 22208 when the neurosurgeon uses a posterior or posterolateral approach for pedicle subtraction osteotomy (PSO), three column closing wedge posterior osteotomy, and vertebral column resection (VCR).

These codes are to be used for osteotomies that remove a V-shaped wedge from the vertebral body, at least two-thirds, along with all of the posterior elements - pedicles, articulating facets, lamina and spinous process.

Depending upon location, you'd use code 22210, 22212 or 22214 for posterior approach in the cervical, thoracic, and lumbar regions, respectively for Ponte osteotomy, posterior closing wedge osteotomy (with or without opening of the anterior column), Smith-Peterson osteotomy, and polysegmental osteotomy. These codes describe osteotomies that remove part or all of the posterior elements but do not remove the vertebral body.

Likewise, if the approach is an anterior one for osteotomy and discectomy and the procedure involves a single vertebral segment, you'd report codes 22220 for the cervical region, 22222 for the thoracic region and 22224 for the lumbar region.

Built in add-ons for multiple levels

For every additional vertebral segment in the posterior or posterolateral approach after the first segment operated upon, report 22216 apart from the primary procedure code.

The CPT book lists the add-on code under each primary approach code for each additional vertebral segment that would need to be billed. For instance, for primary code 22210 for cervical osteotomy of spine posterior approach, 1 vertebral segment, the add-on code for additional vertebral segment would be 22216. Osteotomy procedures are reported as per vertebral level. If the posterior elements were removed from T10, T11 and T12 as in the Ponte or Smith-Peterson osteotomies, you'd report 22212 for T10, 22216 x2 for T11 and T12.

Do not report decompression separately

Decompression of the spinal cord, cauda equina, and/or single or multiple nerve roots is meant in osteotomies and the codes for osteotomies are inclusive of these. Decompression is basically inherent to an osteotomy. These Osteotomy procedures involve removing a piece of the vertebrae to rectify spinal alignment; these codes replace laminectomy, laminotomy, and discectomy procedures and should not be reported at the same levels.

The levels of decompression need to be stated clearly in all operative notes. Minus this documentation, you'd not be able to bill for the decompression separately from the osteotomy. In order to report the right number for every root being decompressed, you should be on the lookout for details for every level to avoid any overlap or to miss reporting a procedure.

Select codes 63047 and 63048 for decompressions that are separate and distinct in anatomical locations from the osteotomy.