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Know the types of cases for which spinal hardware removal is billable

In this Spine Coding Source, Teri Romano, RN, MBA, CPC, CMDP, and Kim Pollock, RN, MBA, CPC, CMDP, provide important details on reinstrumentation and instrument removal codes.

 – Daniel Refai, MD
Associate Editor, Neurosurgery

Daniel Refai

It would be great if the 40 minutes spent meticulously removing previously placed posterior rods and screws in preparation for extension of the instrumentation could be reported and reimbursed using the Current Procedural Terminology or CPT codes for instrumentation removal, but unfortunately that is not always the case. According to the CPT guidelines for use of the spinal instrumentation, as well as the reinsertion and/or removal codes, which are summarized in Table 1, there are limited scenarios in which these codes can be reported.

Teri Romano

The CPT guidelines state: “Only the appropriate insertion code (22840-22848) should be reported when previously placed spinal instrumentation is removed or revised during the same session when new instrumentation is inserted at levels including all or part of the previously placed instrumented segments.” Table 2 shows spinal instrumentation codes 22840-22848. Translated, this means if any of the new hardware that was placed overlaps a level where previous instrumentation had been placed, then only the new instrumentation is able to be reported.

Kim Pollock

How does this work in practice? A review of some common scenarios may help with understanding hardware removal billing.

Report removal codes

The surgeon removes existing rods and screws at L2-4 from a previous surgery. At the same operative session, new instrumentation is placed, but from L5-S1 only. Report the removal of the L2-4 hardware with 22852 and report 22840 for the placement of non-segmental instrumentation at a non-overlapping segment, L5-S1. Append modifier 59 (or an X modifier based on payer preference) on the lower valued code, likely 22852, to indicate the removal and new hardware placement were at totally different levels.

Should instrumentation be removed as the sole procedure performed, such as when the hardware is broken and is no longer needed for stabilization, the appropriate instrumentation removal code is reported (i.e., 22850, 22852, 22855).

Do not report removal codes

The surgeon removes an existing rod and screws at L2-4 from a previous surgery, and places new instrumentation from L4-S1. Report the new instrumentation code only, 22842, since L4 is an overlapping level to the old construct.

 

Also, remember that if previously placed instrumentation was removed and it was replaced at the same vertebral segments, then it is correct to report 22849 (reinsertion of spinal fixation device). Keep in mind CPT 22849 includes the removal of the old hardware and placement of the new at the same level(s) without extension of the construct. Codes for placement of spinal instrumentation (22840-22848) or removal of instrumentation (22850, 22852, 22855) should never be reported in addition to code 22849 unless these activities were performed at entirely different levels of the spine.

Disclosures: Romano and Pollock report no relevant financial disclosures.

In this Spine Coding Source, Teri Romano, RN, MBA, CPC, CMDP, and Kim Pollock, RN, MBA, CPC, CMDP, provide important details on reinstrumentation and instrument removal codes.

 – Daniel Refai, MD
Associate Editor, Neurosurgery

Daniel Refai

It would be great if the 40 minutes spent meticulously removing previously placed posterior rods and screws in preparation for extension of the instrumentation could be reported and reimbursed using the Current Procedural Terminology or CPT codes for instrumentation removal, but unfortunately that is not always the case. According to the CPT guidelines for use of the spinal instrumentation, as well as the reinsertion and/or removal codes, which are summarized in Table 1, there are limited scenarios in which these codes can be reported.

Teri Romano

The CPT guidelines state: “Only the appropriate insertion code (22840-22848) should be reported when previously placed spinal instrumentation is removed or revised during the same session when new instrumentation is inserted at levels including all or part of the previously placed instrumented segments.” Table 2 shows spinal instrumentation codes 22840-22848. Translated, this means if any of the new hardware that was placed overlaps a level where previous instrumentation had been placed, then only the new instrumentation is able to be reported.

Kim Pollock

How does this work in practice? A review of some common scenarios may help with understanding hardware removal billing.

Report removal codes

The surgeon removes existing rods and screws at L2-4 from a previous surgery. At the same operative session, new instrumentation is placed, but from L5-S1 only. Report the removal of the L2-4 hardware with 22852 and report 22840 for the placement of non-segmental instrumentation at a non-overlapping segment, L5-S1. Append modifier 59 (or an X modifier based on payer preference) on the lower valued code, likely 22852, to indicate the removal and new hardware placement were at totally different levels.

Should instrumentation be removed as the sole procedure performed, such as when the hardware is broken and is no longer needed for stabilization, the appropriate instrumentation removal code is reported (i.e., 22850, 22852, 22855).

Do not report removal codes

The surgeon removes an existing rod and screws at L2-4 from a previous surgery, and places new instrumentation from L4-S1. Report the new instrumentation code only, 22842, since L4 is an overlapping level to the old construct.

 

Also, remember that if previously placed instrumentation was removed and it was replaced at the same vertebral segments, then it is correct to report 22849 (reinsertion of spinal fixation device). Keep in mind CPT 22849 includes the removal of the old hardware and placement of the new at the same level(s) without extension of the construct. Codes for placement of spinal instrumentation (22840-22848) or removal of instrumentation (22850, 22852, 22855) should never be reported in addition to code 22849 unless these activities were performed at entirely different levels of the spine.

Disclosures: Romano and Pollock report no relevant financial disclosures.