Billing and Coding: Lumbar Spinal Fusion PLIF, TLIF, ALIF, DLIF, OLIF and Instrumentation

​Orthopedic spinal fusion is a surgical procedure used to join two or more vertebrae in the spine. This process can help stabilize the spine, reduce pain, and correct deformities. Accurate coding and billing for these procedures are essential for proper reimbursement and compliance with healthcare regulations. This guide will explain the key terminology, procedures, techniques, and CPT® codes associated with orthopedic spinal fusion.

Spinal Fusion Techniques and Procedures

Posterior Lumbar Interbody Fusion (PLIF):
Procedure Description: In a PLIF procedure, the surgeon makes a midline incision in the back to access the lumbar spine. The affected disc is removed, and bone graft material is placed between the vertebrae to facilitate fusion. This technique helps alleviate pain caused by conditions such as herniated discs, spinal stenosis, or spinal instability.

• Approach: A midline incision is made in the patient's back to access the lumbar spine.
• Procedure: The surgeon removes the intervertebral disc and prepares the space by performing a laminectomy (removal of part of the vertebral bone called the lamina) and/or discectomy (removal of the disc). Bone graft material is then placed in the intervertebral space to promote fusion of the adjacent vertebrae.
• Indications: This procedure is typically used to treat conditions like herniated discs, spinal stenosis (narrowing of the spinal canal), and spinal instability.
• CPT Codes:
  • 22630: Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar.
  • +22632: Each additional interspace (list separately in addition to code for primary procedure).

Transforaminal Lumbar Interbody Fusion (TLIF):
Procedure Description: Similar to PLIF, TLIF involves a posterior approach but accesses the vertebral body at an angle. The surgeon makes an incision on the side of the spine, removes the affected disc, and inserts bone graft material to promote fusion. This technique minimizes disruption to the spinal muscles and may reduce recovery time.

• Approach: An incision is made on the side of the spine, providing a more lateral approach compared to PLIF.
• Procedure: The surgeon removes the affected disc through the transforaminal route, which involves accessing the disc space through the foramen (an opening in the vertebrae). Bone graft material is placed in the intervertebral space to facilitate fusion. This technique minimizes disruption to the paraspinal muscles.
• Indications: TLIF is used for similar indications as PLIF, but the lateral approach can result in less muscle damage and potentially quicker recovery.
• CPT Codes:
  • 22633: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar.
  • +22634: Each additional interspace (list separately in addition to code for primary procedure).

Anterior Lumbar Interbody Fusion (ALIF):
Procedure Description: In an ALIF procedure, the surgeon makes an incision in the abdomen to access the spine. The affected disc is removed, and bone graft material is placed in the intervertebral space to promote fusion. This approach avoids the posterior muscles and nerves, potentially reducing postoperative pain. 

• Approach: The surgeon makes an incision in the abdomen to access the spine from the front.
  
• Procedure: The affected disc is removed, and the intervertebral space is prepared. Bone graft material is placed in the space to promote fusion. This anterior approach avoids the back muscles and nerves, potentially reducing postoperative pain and complications related to muscle damage.
  
• Indications: ALIF is used for similar conditions as PLIF and TLIF but provides the advantage of avoiding posterior muscle disruption.
  • CPT Codes:
    • 22558: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
    • +22585: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (list separately in addition to code for primary procedure).

Direct Lateral Interbody Fusion (DLIF):
Procedure Description: The surgeon makes an incision on the patient's side to access the intervertebral space anteriorly. This technique minimizes disruption to muscles and nerves, providing a clear path to the interbody space. Bone graft material is placed between the vertebrae to facilitate fusion.
​

• Approach: An incision is made on the patient's side to access the spine laterally.
• Procedure: The surgeon uses a lateral approach to avoid the major muscles and nerves. The disc is removed and replaced with bone graft material to facilitate fusion.
• Indications: DLIF is beneficial for patients needing a minimally invasive approach that minimizes muscle disruption and nerve damage.
• CPT Codes:
  • 22558: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
  • +22585: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (list separately in addition to code for primary procedure).

Oblique Lateral Interbody Fusion (OLIF):
Procedure Description: In an OLIF procedure, the surgeon makes an oblique incision to access the interbody space, avoiding the psoas muscle and minimizing the risk of nerve damage. Bone graft material is inserted to promote fusion.

• Approach: An oblique incision is made to access the interbody space from an angle that avoids the psoas muscle.
• Procedure: The oblique angle allows the surgeon to avoid the major nerves in the psoas muscle, reducing the risk of nerve damage. Bone graft material is placed in the intervertebral space to facilitate fusion.
• Indications: OLIF is used for patients who need a minimally invasive approach that reduces the risk of nerve damage.
• CPT Codes:
  • 22558: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
  • +22585: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (list separately in addition to code for primary procedure).

​

Instrumentation for Spinal Fusion

Posterior Instrumentation:
​Instrumentation provides stability to the spine and supports the fusion process. Different types of posterior instrumentation include non-segmental and segmental fixation methods.

• Purpose: Provides stability to the spine from the back and supports the fusion process.
  
• Types:
  • Spinous process wiring: Involves internal spinal fixation using wires to stabilize the spine.
    • CPT Code: +22841: Internal spinal fixation by wiring of spinous processes.
  • Segmental instrumentation: Uses multiple fixation points for enhanced stability, involving dual rods, multiple hooks, and sublaminar wires.
    • 3 to 6 segments: +22842: Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires).
    • 7 to 12 segments: +22843: Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires).
    • 13 or more segments: +22844: Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires).
  • Non-segmental instrumentation: Involves simpler fixation methods like Harrington rods or pedicle screws spanning a single interspace.
    • CPT Code: +22840: Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation).

Anterior Instrumentation:
Anterior instrumentation is used to stabilize the spine through an anterior approach. These procedures often involve inserting rods, screws, and other hardware from the front of the spine to provide support and promote fusion.

• Purpose: Stabilizes the spine from the front.
• Types:
  • Instrumentation across multiple segments:
    • 2 to 3 segments: +22845.
    • 4 to 7 segments: +22846.
    • 8 or more segments: +22847.
  • Pelvic fixation: Attaches the end of the instrumentation to the pelvic bones.
    • CPT Code: +22848.

• +22845: Anterior instrumentation; 2 to 3 vertebral segments (list separately in addition to code for primary procedure).
• +22846: Anterior instrumentation; 4 to 7 vertebral segments (list separately in addition to code for primary procedure).
• +22847: Anterior instrumentation; 8 or more vertebral segments (list separately in addition to code for primary procedure).
• +22848: Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (list separately in addition to code for primary procedure).

Spinal Prosthetic Devices:
Spinal prosthetic devices are crucial in maintaining disc space and providing spinal stability, particularly when natural disc material is removed. These devices, such as synthetic cages and meshes, help maintain the proper alignment of the spine and can promote bone growth.​

• Purpose: Maintain disc space and alignment, support fusion, and provide spinal stability.
• Types:
  • Interbody biomechanical devices: These devices include synthetic cages and meshes that provide structural support and facilitate fusion.
    • With integral anterior instrumentation: +22853: Insertion of interbody biomechanical device(s) with integral anterior instrumentation.
    • For vertebral body resection defects: +22854: Insertion of intervertebral biomechanical device(s) with integral anterior instrumentation for vertebral corpectomy(ies) defect.
    • Without interbody arthrodesis: +22859: Insertion of intervertebral biomechanical device(s) to intervertebral disc space or vertebral body defect without interbody arthrodesis.

Bone Grafting: 
Bone grafting is an essential part of spinal fusion procedures, as it facilitates the growth of new bone tissue to achieve a successful fusion. Different types of bone grafts include autografts, allografts, and synthetic grafts.

• Purpose: Promote new bone growth to ensure successful fusion.
• Types:
  • Allografts: Bone grafts taken from a donor and processed for safe use.
    • Morselized or osteopromotive material: +20930: Allograft, morselized, or placement of osteopromotive material.
    • Structural allografts: +20931: Allograft, structural.
  • Autografts: Bone grafts harvested from the patient's own body.
    • Local grafts from the same incision: +20936: Autograft for spine surgery only, local.
    • Morselized grafts from separate incision: +20937: Autograft for spine surgery only, morselized.
    • Structural grafts from separate incision: +20938: Autograft for spine surgery only, structural, bicortical or tricortical.

Billing and Coding tips: Prosthetic Devices:

​​CPT Code 22853: Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure).
Breakdown of CPT Code 22853Components of the Procedure:

1. Insertion of Interbody Biomechanical Device:
   • This refers to the placement of a device such as a synthetic cage or mesh between the vertebrae in the intervertebral disc space. These devices help maintain the space between the vertebrae, provide stability, and promote bone fusion.
2. Integral Anterior Instrumentation:
   • This involves the use of instrumentation (e.g., screws, flanges) that is an integral part of the interbody device. The instrumentation helps anchor the device securely to the vertebral bodies.
3. Interbody Arthrodesis:
   • Arthrodesis is the surgical fusion of two bones. In this context, it refers to the fusion of vertebrae across the intervertebral disc space using the interbody device and instrumentation.

Key Points:

• Add-On Code: CPT 22853 is an add-on code and must be billed in addition to a primary procedure code. It cannot be billed as a standalone code.
• Each Interspace: The code should be reported for each intervertebral disc space where the device and instrumentation are used. If devices are placed at multiple levels, the code is listed separately for each level.
• Documentation: The operative report must include detailed documentation of the procedure, including the insertion of the device and the instrumentation used.

Clinical Example:Scenario:Patient: Jane Doe, 50-year-old female.
Diagnosis: Severe lumbar disc degeneration and spondylolisthesis at L4-L5 causing chronic back pain and radiculopathy.
Procedure: Anterior Lumbar Interbody Fusion (ALIF) at L4-L5 with insertion of a synthetic cage and anterior instrumentation.
Coding and Billing:

1. Primary Procedure Code:
   • 22558: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
2. Add-On Code:
   • +22853: Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring, each interspace.
3. ICD-10 Diagnosis Codes:
   • M51.36: Other intervertebral disc degeneration, lumbar region.
   • M43.16: Spondylolisthesis, lumbar region.
4. Modifiers (if applicable):
   • Modifier 62: If two surgeons are involved.
   • Modifier 51: For multiple procedures.
   • Modifier 80: For assistant surgeon.
5. Place of Service Code:
   • 21: Inpatient hospital, or
   • 22: Outpatient hospital.

Detailed Operative Report:Operative Report for Jane Doe:

• Preoperative Diagnosis: Severe lumbar disc degeneration and spondylolisthesis at L4-L5.
• Postoperative Diagnosis: Same.
• Procedure: Anterior Lumbar Interbody Fusion (ALIF) at L4-L5, insertion of synthetic cage with anterior instrumentation.
• Surgeon: Dr. John Smith
• Assistant Surgeon: Dr. Jane Williams (if applicable)

Procedure Description:

1. Approach: The patient was positioned supine, and a lower abdominal incision was made to expose the L4-L5 intervertebral space.
2. Discectomy: The disc material at L4-L5 was excised, and the endplates were prepared to receive the interbody device.
3. Device Insertion: A synthetic cage filled with autograft bone was inserted into the intervertebral disc space at L4-L5.
4. Instrumentation: Anterior instrumentation, including screws and flanges, was used to anchor the cage securely to the vertebral bodies.
5. Closure: Hemostasis was achieved, and the incision was closed in layers.
6. Outcome: The patient tolerated the procedure well and was transferred to the recovery room in stable condition.

Summary:

• CPT 22853 is used for the insertion of interbody devices with integral anterior instrumentation during interbody arthrodesis.
• Report per Interspace: The code should be reported for each intervertebral disc space treated.
• Add-On Code: Always listed separately in addition to the primary procedure code.
• Documentation: Detailed documentation in the operative report is essential to support the use of CPT 22853.

By following these guidelines, healthcare providers can ensure accurate billing and coding for procedures involving CPT 22853, leading to proper reimbursement and compliance with payer 

Example Clinical Cases with Instrumentation, Billing & Coding, Place of Service, Technical and Professional Fees, Modifiers, Global Period, ICD-10 Codes, Clinical Policies, and Local Coverage Determination

Spinal Fusion Insurance Prior Authorization Services, Patients and Revenue Cycle Management

1. Posterior Lumbar Interbody Fusion (PLIF)
Clinical Case:

• Patient: John Doe, 55-year-old male.
• Diagnosis: Degenerative disc disease and severe spinal stenosis at L4-L5 causing significant lower back pain and radiculopathy.
• Procedure: PLIF at L4-L5.
• Details: A midline incision was made, the affected disc was removed, and a bone graft was placed to facilitate fusion. Posterior instrumentation with pedicle screws and rods was used to stabilize the spine.

Billing and Coding:

• Primary CPT Code:
  • 22630: Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar.
• Additional CPT Code (if more than one interspace is involved):
  • +22632: Each additional interspace (list separately in addition to code for primary procedure).
• Instrumentation Codes:
  • +22840: Posterior non-segmental instrumentation (e.g., pedicle fixation across 1 interspace).

ICD-10 Codes:

• M51.36: Other intervertebral disc degeneration, lumbar region.
• M48.061: Spinal stenosis, lumbar region without neurogenic claudication.

Modifiers:

• Modifier 62: If two surgeons are involved.
• Modifier 51: For multiple procedures.
• Modifier 80: For assistant surgeon.

Place of Service:

• 21: Inpatient hospital.
• 22: Outpatient hospital.

Technical and Professional Fees:

• 22630:
  • Technical Fee: Costs associated with the use of hospital facilities and equipment.
  • Professional Fee: Costs associated with the surgeon’s expertise and time.
• +22632:
  • Technical Fee: Additional costs for the use of hospital facilities and equipment for each extra interspace.
  • Professional Fee: Additional costs for the surgeon’s expertise and time for each extra interspace.
• +22840:
  • Technical Fee: Costs associated with hospital facilities and equipment.
  • Professional Fee: Costs associated with the surgeon’s expertise and time.

Global Period: 90 days.
Clinical Policies and Local Coverage Determination:

• Clinical Policy: UnitedHealthcare, "Lumbar Spinal Fusion and Lumbar Total Disc Arthroplasty."
  • Policy Number: CS0828
  • URL: UnitedHealthcare Clinical Policy
  • Summary: This policy covers the indications for lumbar spinal fusion, including specific criteria for patient selection, necessary documentation, and contraindications. It highlights the importance of conservative treatment prior to surgical intervention.
• Local Coverage Determination: Noridian, "Lumbar Spinal Fusion for Degenerative Disc Disease (L34975)."
  • Policy Number: L34975
  • Summary: This LCD provides guidelines for the coverage of lumbar spinal fusion, including patient selection criteria, preoperative conservative treatment requirements, and documentation needed to justify the procedure. The policy aims to ensure that fusion is performed only when medically necessary and appropriately documented.

2. Transforaminal Lumbar Interbody Fusion (TLIF)
Clinical Case:

• Patient: Jane Smith, 48-year-old female.
• Diagnosis: Herniated disc at L5-S1 with left-sided radiculopathy.
• Procedure: TLIF at L5-S1.
• Details: An incision was made on the left side of the spine, the affected disc was removed through a transforaminal route, and a bone graft was placed. Posterior instrumentation with pedicle screws and rods was used to stabilize the spine.

Billing and Coding:

• Primary CPT Code:
  • 22633: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar.
• Additional CPT Code (if more than one interspace is involved):
  • +22634: Each additional interspace (list separately in addition to code for primary procedure).
• Instrumentation Codes:
  • +22842: Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments.

ICD-10 Codes:

• M51.17: Intervertebral disc disorders with radiculopathy, lumbosacral region.
• M48.061: Spinal stenosis, lumbar region without neurogenic claudication.

Modifiers:

• Modifier 62: If two surgeons are involved.
• Modifier 51: For multiple procedures.
• Modifier 80: For assistant surgeon.

Place of Service:

• 21: Inpatient hospital.
• 22: Outpatient hospital.

Technical and Professional Fees:

• 22633:
  • Technical Fee: Costs associated with the use of hospital facilities and equipment.
  • Professional Fee: Costs associated with the surgeon’s expertise and time.
• +22634:
  • Technical Fee: Additional costs for the use of hospital facilities and equipment for each extra interspace.
  • Professional Fee: Additional costs for the surgeon’s expertise and time for each extra interspace.
• +22842:
  • Technical Fee: Costs associated with hospital facilities and equipment.
  • Professional Fee: Costs associated with the surgeon’s expertise and time.

Global Period: 90 days.
Clinical Policies and Local Coverage Determination:

• Clinical Policy: Aetna, "Lumbar Spinal Fusion Surgery."
  • Policy Number: 0277
  • Summary: This policy outlines the criteria for lumbar spinal fusion surgery coverage, including specific indications, necessary preoperative conservative treatments, and documentation requirements. It emphasizes the importance of patient selection and proper documentation to ensure medical necessity.
• Local Coverage Determination: Palmetto GBA, "Lumbar Spinal Fusion (L37305)."
  • Policy Number: L37305
  • Summary: This LCD specifies the guidelines for lumbar spinal fusion, including patient criteria, conservative treatment prerequisites, and required documentation. The policy aims to ensure the procedure is medically necessary and appropriately documented.

Billing and Coding: Lumbar Spinal Fusion PLIF, TLIF, ALIF, DLIF, OLIF and Instrumentation

3. Anterior Lumbar Interbody Fusion (ALIF)
Clinical Case:

• Patient: Robert Johnson, 60-year-old male.
• Diagnosis: Severe degenerative disc disease at L3-L4 with instability.
• Procedure: ALIF at L3-L4.
• Details: An anterior incision was made, the affected disc was removed, and a bone graft was placed to facilitate fusion. Anterior instrumentation with plates and screws was used to stabilize the spine.

Billing and Coding:

• Primary CPT Code:
  • 22558: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
• Additional CPT Code (if more than one interspace is involved):
  • +22585: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (list separately in addition to code for primary procedure).
• Instrumentation Codes:
  • +22845: Anterior instrumentation; 2 to 3 vertebral segments.

ICD-10 Codes:

• M51.36: Other intervertebral disc degeneration, lumbar region.
• M43.16: Spondylolisthesis, lumbar region.

Modifiers:

• Modifier 62: If two surgeons are involved.
• Modifier 51: For multiple procedures.
• Modifier 80: For assistant surgeon.

Place of Service:

• 21: Inpatient hospital.
• 22: Outpatient hospital.

Technical and Professional Fees:

• 22558:
  • Technical Fee: Costs associated with the use of hospital facilities and equipment.
  • Professional Fee: Costs associated with the surgeon’s expertise and time.
• +22585:
  • Technical Fee: Additional costs for the use of hospital facilities and equipment for each extra interspace.
  • Professional Fee: Additional costs for the surgeon’s expertise and time for each extra interspace.
• +22845:​
  • Professional Fee: Costs associated with the surgeon’s expertise and time.
  • Technical Fee: Costs associated with hospital facilities and equipment.

Global Period: 90 days.
Clinical Policies and Local Coverage Determination:

• Clinical Policy: Blue Cross Blue Shield, "Lumbar Fusion Surgery."
  • Policy Number: SUR706.009
  • Summary: This policy provides guidelines on indications for lumbar fusion surgery, including the criteria for patient selection, necessary preoperative conservative treatments, and the documentation required to justify the procedure. It emphasizes the importance of verifying medical necessity and ensuring that all other non-surgical options have been exhausted before proceeding with surgery.
• Local Coverage Determination: Novitas Solutions, "Lumbar Spinal Fusion (L35172)."
  • Policy Number: L35172
  • ​Summary: This LCD outlines the criteria for lumbar spinal fusion, including patient selection guidelines, conservative treatment prerequisites, and the documentation needed to justify the procedure. The policy aims to ensure that lumbar fusion is only performed when it is medically necessary and appropriately documented.

4. Direct Lateral Interbody Fusion (DLIF)
Clinical Case:

• Patient: Emily Davis, 52-year-old female.
• Diagnosis: Spondylolisthesis at L2-L3 causing neurogenic claudication.
• Procedure: DLIF at L2-L3.
• Details: A lateral incision was made, the affected disc was removed, and a bone graft was placed through the lateral corridor. Lateral instrumentation with cages and screws was used to stabilize the spine.

Billing and Coding:

• Primary CPT Code:
  • 22558: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
• Additional CPT Code (if more than one interspace is involved):
  • +22585: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (list separately in addition to code for primary procedure).
• Instrumentation Codes:
  • +22853: Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges).

ICD-10 Codes:

• M43.16: Spondylolisthesis, lumbar region.
• M48.062: Spinal stenosis, lumbar region with neurogenic claudication.

Modifiers:

• Modifier 62: If two surgeons are involved.
• Modifier 51: For multiple procedures.
• Modifier 80: For assistant surgeon.

Place of Service:

• 21: Inpatient hospital.
• 22: Outpatient hospital.

Technical and Professional Fees:

• 22558:
  • Technical Fee: Costs associated with the use of hospital facilities and equipment.
  • Professional Fee: Costs associated with the surgeon’s expertise and time.
• +22585:
  • Technical Fee: Additional costs for the use of hospital facilities and equipment for each extra interspace.
  • Professional Fee: Additional costs for the surgeon’s expertise and time for each extra interspace.
• +22853:
  • Technical Fee: Costs associated with hospital facilities and equipment.
  • Professional Fee: Costs associated with the surgeon’s expertise and time.

Global Period: 90 days.
Clinical Policies and Local Coverage Determination:

• Clinical Policy: Cigna, "Lumbar Spinal Fusion Surgery."
  • Policy Number: 0278
  • URL: Cigna Clinical Policy
  • Summary: This policy outlines the indications for lumbar spinal fusion surgery, including criteria for patient selection, necessary conservative treatment measures prior to surgery, and required documentation. It emphasizes the need for thorough patient evaluation and adherence to guidelines to ensure medical necessity.
• Local Coverage Determination: WPS Government Health Administrators, "Lumbar Spinal Fusion (L34823)."
  • Policy Number: L34823
  • URL: WPS GHA LCD
  • Summary: This LCD specifies the guidelines for lumbar spinal fusion, including patient criteria, required conservative treatments, and necessary documentation. The policy aims to ensure that lumbar fusion procedures are performed based on medical necessity and proper documentation.

5. Oblique Lateral Interbody Fusion (OLIF)
Clinical Case:

• Patient: Michael Brown, 65-year-old male.
• Diagnosis: Degenerative scoliosis with lumbar radiculopathy at L2-L3.
• Procedure: OLIF at L2-L3.
• Details: An oblique incision was made, avoiding the psoas muscle, and the affected disc was removed and replaced with a bone graft. Oblique lateral instrumentation with cages and screws was used to stabilize the spine.

Billing and Coding:

• Primary CPT Code:
  • 22558: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
• Additional CPT Code (if more than one interspace is involved):
  • +22585: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (list separately in addition to code for primary procedure).
• Instrumentation Codes:
  • +22853: Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges).

ICD-10 Codes:

• M41.26: Other idiopathic scoliosis, lumbar region.
• M43.16: Spondylolisthesis, lumbar region.

Modifiers:

• Modifier 62: If two surgeons are involved.
• Modifier 51: For multiple procedures.
• Modifier 80: For assistant surgeon.

Place of Service:

• 21: Inpatient hospital.
• 22: Outpatient hospital.

Technical and Professional Fees:

• 22558:
  • Technical Fee: Costs associated with the use of hospital facilities and equipment.
  • Professional Fee: Costs associated with the surgeon’s expertise and time.
• +22585:
  • Technical Fee: Additional costs for the use of hospital facilities and equipment for each extra interspace.
  • Professional Fee: Additional costs for the surgeon’s expertise and time for each extra interspace.
• +22853:
  • Technical Fee: Costs associated with hospital facilities and equipment.
  • Professional Fee: Costs associated with the surgeon’s expertise and time.

Global Period: 90 days.
Clinical Policies and Local Coverage Determination:

• Clinical Policy: Humana, "Lumbar Spinal Fusion."
  • Policy Number: HUM-0527
  • URL: Humana Clinical Policy
  • Summary: This policy covers the indications for lumbar spinal fusion surgery, including patient selection criteria, necessary preoperative conservative treatments, and required documentation. It emphasizes thorough patient evaluation and adherence to guidelines to ensure medical necessity.
• Local Coverage Determination: CGS Administrators, "Lumbar Spinal Fusion (L33828)."
  • Policy Number: L33828
  • URL: CGS Administrators LCD
  • Summary: This LCD outlines the criteria for lumbar spinal fusion, including patient selection guidelines, conservative treatment prerequisites, and the documentation needed to justify the procedure. The policy aims to ensure that lumbar fusion procedures are performed based on medical necessity and proper documentation.

Reporting Co-surgeries for Spinal Fusion Procedures

Source: CPT®  Assistant July 1996 page 7
Coding Tip
Reporting Cosurgeries
"We receive many questions concerning how to report surgeries performed by more than one physician. To help you understand the proper coding we present the following information."
The General Question
"I am a general surgeon who sometimes performs surgeries with other surgeons (cosurgeries), such as orthopedic or neurosurgeons. I open the surgical site, the other surgeon does the definitive portion of the procedure, and then I close. What CPT codes should I report for my services? I have heard from some sources that I should bill for a thoracotomy and wound repair. But other sources have told me to report the same CPT codes as the other surgeon. Which is correct?

CPT® ​ASSISTANT'S REPLY:
Here's How to Code:
"For situations in which one surgeon performs the opening and closing of a surgery and another physician performs the definitive portion of the procedure, both physicians should report the same CPT codes, and appropriately append either modifier -62 or modifier -66."

Illustration
A patient's surgery includes arthrodesis of two interspaces of the thoracic spine by anterior interbody technique, with anterior instrumentation of three vertebral segments. Physician "A" performs a thoracotomy at the start of the surgical session, and Physician "B" performs the arthrodesis and spinal instrumentation. Upon completion of the arthrodesis and spinal instrumentation, Physician A closes the operative site. 
Coding the Illustration
(The physicians in the illustration would report the codes indicated below.)
Physician A       22556-62
Physician B       22556-62
22558-62
22558-62

22845-62
22845-62
When performing these cosurgeries, it is important to communicate with the other surgeon's office to be certain that you submit the claims properly

Important Billing and Coding Tips for Lumbar Spinal Fusion Procedures

1. Thorough Documentation: Ensure detailed documentation of the patient's history, physical examination findings, imaging results, and conservative treatments. Clear, comprehensive documentation supports the medical necessity of the procedure and facilitates accurate coding.
2. Understand and Follow Payer Guidelines: Familiarize yourself with the specific requirements of the clinical policies and local coverage determinations (LCDs) from different payers. Adhering to these guidelines helps in meeting medical necessity criteria and avoiding denials.
3. Use Correct CPT and ICD-10 Codes: Accurate coding is crucial. Ensure you use the correct CPT codes for the specific procedure performed and the appropriate ICD-10 codes for the diagnosis. Double-check for any updates in coding guidelines annually.
4. Apply Modifiers Appropriately: Use modifiers to indicate specific circumstances of the procedure, such as:
   • Modifier 62: Two surgeons involved.
   • Modifier 51: Multiple procedures performed during the same session.
   • Modifier 80: Assistant surgeon involved.
   • Modifier 59: Distinct procedural service when needed to indicate a different procedure/site.
5. Conservative Treatment Documentation: Document all conservative treatments tried before opting for surgery, such as physical therapy, medication management, and other non-surgical interventions. This is often a requirement for insurance approval.
6. Preauthorization: Obtain preauthorization from the insurance provider before performing the surgery. This ensures that the payer agrees the procedure is medically necessary and reduces the risk of claim denials.
7. Understand Instrumentation and Grafting Codes: Be familiar with the CPT codes for instrumentation (e.g., +22840, +22842) and bone grafting (e.g., +20930, +20936) to accurately report the services provided during the surgery.
8. Monitor Updates and Changes: Stay informed about updates to coding guidelines, payer policies, and LCDs. Regularly reviewing resources such as the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) websites helps in keeping current with changes.
9. Detailed Operative Reports: Ensure that the operative reports are detailed and clearly outline the procedures performed, including the type of fusion, instrumentation used, and any additional procedures. This supports accurate coding and billing.
10. Check for Bundled Services: Be aware of services that may be bundled into a single CPT code. For example, certain instrumentation and bone grafting procedures may be included in the primary procedure code.
11. Postoperative Care and Global Period: Understand the global period for each procedure (typically 90 days for spinal fusions) and ensure that postoperative care is included within this period unless additional services are required that are unrelated to the surgery.
12. Use Correct Place of Service Codes: Accurately report the place of service (e.g., 21 for inpatient hospital, 22 for outpatient hospital) to ensure correct payment rates and compliance with payer requirements.

By following these best practices, healthcare providers can improve the accuracy of their billing and coding for lumbar spinal fusion surgeries, ensure compliance with payer requirements, and optimize reimbursement. Thorough documentation, understanding payer guidelines, accurate coding, and staying updated with changes are key to successful billing and coding in spinal fusion procedures.

​Best Practices and Compliance for Lumbar Spinal Fusion Billing and Coding

Billing and Coding: Lumbar Spinal Fusion PLIF, TLIF, ALIF, DLIF, OLIF and Instrumentation

1. Comprehensive Documentation:
   • Maintain detailed and accurate patient records, including history, physical examination findings, imaging studies, and the outcomes of conservative treatments.
   • Ensure that all documentation supports the medical necessity of the spinal fusion procedure.
2. Accurate Coding:
   • Use the correct CPT and ICD-10 codes specific to the procedure and diagnosis.
   • Regularly review coding updates and guidelines to stay current.
   • Double-check codes for accuracy before submission to avoid claim denials.
3. Preauthorization:
   • Obtain preauthorization from insurance companies before performing the surgery.
   • Document the preauthorization approval in the patient's medical record.
   • Verify the requirements for preauthorization with each payer, as they may vary.
4. Patient Selection Criteria:
   • Follow the patient selection criteria outlined in clinical policies and LCDs.
   • Ensure that conservative treatments have been attempted and documented before surgery.
   • Consider alternative treatments and document why they were not viable options for the patient.
5. Use of Modifiers:
   • Apply appropriate modifiers to indicate special circumstances, such as multiple procedures or the involvement of additional surgeons.
   • Common modifiers include:
     • Modifier 62: Two surgeons
     • Modifier 51: Multiple procedures
     • Modifier 80: Assistant surgeon
     • Modifier 59: Distinct procedural service
6. Global Period Compliance:
   • Understand and adhere to the global period for spinal fusion surgeries, typically 90 days.
   • Include all postoperative care within the global period unless it involves a separate, unrelated issue.
7. Place of Service Codes:
   • Accurately report the place of service codes to reflect where the procedure was performed.
   • Common codes include:
     • 21: Inpatient hospital
     • 22: Outpatient hospital
8. Clinical Policies and LCD Adherence:
   • Familiarize yourself with clinical policies and LCDs from various payers to ensure compliance.
   • Follow guidelines on patient selection, conservative treatment documentation, and required diagnostic tests.
   • Keep updated with any changes to these policies.
9. Coding for Instrumentation and Grafting:
   • Use specific CPT codes for instrumentation (e.g., +22840, +22842) and bone grafting (e.g., +20930, +20936).
   • Ensure that the use of these codes is well-documented in the operative report.
10. Detailed Operative Reports:
    • Provide detailed operative reports that clearly describe the procedures performed, including the type of fusion, instrumentation used, and any additional procedures.
    • Ensure that reports are comprehensive and support the codes billed.
11. Regular Training and Education:
    • Engage in continuous education and training for all staff involved in billing and coding.
    • Attend seminars, webinars, and workshops to stay informed about the latest coding practices and compliance requirements.
12. Audit and Review:
    • Conduct regular internal audits to identify and correct billing and coding errors.
    • Implement corrective actions and provide training based on audit findings.
    • Utilize external audits periodically to ensure compliance and accuracy.
13. Patient Communication:
    • Clearly communicate with patients about the procedure, expected outcomes, and any financial responsibilities.
    • Provide patients with information about the need for preauthorization and the importance of following preoperative and postoperative care instructions.
14. EHR and Billing Software Utilization:
    • Use electronic health records (EHR) and billing software to streamline documentation and coding processes.
    • Ensure that the software is updated regularly to incorporate the latest coding changes and guidelines.

By adhering to these best practices and compliance guidelines, healthcare providers can ensure accurate billing and coding, support medical necessity, optimize reimbursement, and minimize the risk of claim denials and audits. Thorough documentation, ongoing education, regular audits, and clear patient communication are essential components of an effective billing and coding strategy for lumbar spinal fusion surgeries.

Citations and Sources:

1. UnitedHealthcare Clinical Policy on Lumbar Spinal Fusion and Lumbar Total Disc Arthroplasty
   • Policy Number: CS0828
   • URL: UnitedHealthcare Clinical Policy
2. Noridian LCD on Lumbar Spinal Fusion for Degenerative Disc Disease
   • Policy Number: L34975
   • URL: Noridian LCD
3. Aetna Clinical Policy on Lumbar Spinal Fusion Surgery
   • Policy Number: 0277
   • URL: Aetna Clinical Policy
4. Palmetto GBA LCD on Lumbar Spinal Fusion
   • Policy Number: L37305
   • URL: Palmetto GBA LCD
5. Blue Cross Blue Shield Clinical Policy on Lumbar Fusion Surgery
   • Policy Number: SUR706.009
   • URL: BCBS Clinical Policy
6. Novitas Solutions LCD on Lumbar Spinal Fusion
   • Policy Number: L35172
   • URL: Novitas LCD
7. Cigna Clinical Policy on Lumbar Spinal Fusion Surgery
   • Policy Number: 0278
   • URL: Cigna Clinical Policy
8. WPS Government Health Administrators LCD on Lumbar Spinal Fusion
   • Policy Number: L34823
   • URL: WPS GHA LCD
9. Humana Clinical Policy on Lumbar Spinal Fusion
   • Policy Number: HUM-0527
   • URL: Humana Clinical Policy
10. CGS Administrators LCD on Lumbar Spinal Fusion
    • Policy Number: L33828
    • URL: CGS Administrators LCD
11. Anthem Blue Cross Clinical Policy on Lumbar Spinal Fusion
    • Policy Number: SURG.00085
    • URL: Anthem Blue Cross Clinical Policy
12. First Coast Service Options LCD on Lumbar Spinal Fusion
    • Policy Number: L33988
    • URL: First Coast LCD
13. CPT Code Book (2020, 2021, 2022, 2023, 2024)
14. ICD-10 Current 2024​

These references provide detailed information on the criteria, indications, conservative treatment requirements, and documentation standards for lumbar spinal fusion surgeries. Healthcare providers should regularly review these documents to stay updated on the latest guidelines and ensure compliance with payer requirements.

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