This page addresses follow-up questions and additional information pertinent to our webinar
Next Level Spine Coding Part 2: Walking Through Case Studies for Anterior Spinal Fusions.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.
Q: Sometimes we have a scenario where the patient is supposed to have a combination anterior and posterior arthrodesis the same day, but due to blood loss or other complications, only and anterior work is done, and the surgeon decides to bring the patient back in the next day or two to complete the posterior portion, what modifier should we use?
A: This would be a scenario to report modifier 58, it would be considered planned or staged when the patient has the posterior portion completed.
Q: Can we report an anterior vertebral corpectomy code, cervical, for removal of osteophytes from the vertebral body?
A: Not unless the documentation also supports the CPT definition of cervical corpectomy, which requires at least 50% of the vertebral body to be removed.
Q: If during a cervical total disc arthroplasty, the provider documents a complete decompression of the nerve roots and spinal cord, can we also report a decompression at that level?
A: Referring to the anterior arthroplasty code, 22856, it includes a decompression in the code description, so it would not appropriate to separately report a decompression at the same interspace as the total disc arthroplasty.
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Deanna Upston, CPMA, CPC, COSC
Consultant
Deanna is a consultant for The Haugen Consulting Group with over 20 years of health care industry experience. Her introduction was through medical assisting, which she enjoyed for several years. Once she was established at a surgeon’s office, she started coding their surgical cases and discovered that was her favorite part of the day. Deanna has experience working on the professional fee side of coding, audit, education and compliance serving coders and physicians. She has put together multiple education sessions for both provider and coder. She also has experience working as an analyst in which she validated the integrity of editing logic during the implementation of claim scrubbing software.
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