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Spinal Fusion – Documentation Requirements and Coding

An in-depth overview of Lumbar Spinal Fusion – Learn about the coding updates and documentation requirements for spinal fusion procedures. <br>

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Spinal Fusion – Documentation Requirements and Coding

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  1. www.outsourcestrategies.com

  2. Spinal Arthrodesis - a Billable Procedure Lumbar spinal fusion is a surgical procedure performed to fuse together the painful vertebrae so that they heal into a single, solid bone Orthopedic surgeons perform spinal fusion surgery or spinal arthrodesis to restrict spinal motion in order to relieve painful symptoms. Orthopedics medical billing involves preparation of medical documentation with the updated spine codes published by the Centers for Medicare and Medicaid Service (CMS). www.outsourcestrategies.com

  3. Documentation Requirements Approval of claims entailing major procedures requires documentation supporting the reasonableness and necessity of the procedure. Physicians must make sure that the submitted documentation includes History and Physical Duration/character/location/radiation of pain Activity of daily living (ADL) limitations Physical examination www.outsourcestrategies.com

  4. CPT Coding for Spinal Arthrodesis • CPT codes for Posterior Lumbar It is critical for practices to report the correct CPT arthrodesis code(s), based on whether the approach was posterior or anterior. • “Posterior, Posterolateral or Lateral Transverse Process Technique Arthrodesis Procedures on the Spine (Vertebral Column)” • 22612, +22614, 22630, +22632, 22633, +22634 www.outsourcestrategies.com

  5. Codes for Anterior Lumbar Anterior or Anterolateral Approach Technique Arthrodesis Procedures on the Spine (Vertebral Column) - 22558, +22585 For anterior approach to reach the damaged vertebrae, with an incision made through the neck for cervical vertebrae - 22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 For resection of a single vertebral body - 63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment www.outsourcestrategies.com

  6. Codes for Primary Procedure If the physician prepared and inserted an allograft - +20931 Allograft, structural, for spine surgery only For the anterior instrumentation of two to three vertebral segments - +22845 Anterior instrumentation; 2 to 3 vertebral segments www.outsourcestrategies.com

  7. Lateral For the initial thoracic level the surgeon treats using lateral extracavitary approach - 22532 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than decompression); thoracic For each additional level the surgeon treats beyond the initial thoracic level, report add-on code - +22534 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than decompression); thoracic or lumbar, each additional vertebral segment For procedures contained to the lumbar region - 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than decompression); lumbar www.outsourcestrategies.com

  8. CONTACT Headquarters:8596 E. 101st Street, Suite HTulsa, OK 74133Main: (800) 670 2809Fax: (877) 835-5442E-mail:info@managedoutsource.comURL:http://www.outsourcestrategies.com Professional medical billing and coding companies provide the services of experienced medical coders. Medical coders review the operative notes to determine where the instrument was used, and whether it was non-segmental, segmental, or intervertebral and assign the correct medical codes. www.outsourcestrategies.com

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