Surgical Coding/Orders
Name
First Name
Last Name
Update Patient Status
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Surgery to be performed:
ACDF
ACDA
Odontoid Screw
Cervical Corpectomy, 1 level
Cervical Corpectomy, 2 level
Cervical Corpectomy, one level with adjacent ACDF
Cervical Corpectomy "Hybrid" (Two Level ACDF=ACDF + Corp)
Posterior Cervical Laminectomy
Posterior Cervical Fusion
Spinal Cord Stimulation (SCS)
Lumbar Laminectomy
Thoracic Laminectomy
Microdiskectomy
Lumbar TDR
TLIF
ALIF
LLIF
PLF (MinuteMan,Removal of instr)
Kyphoplasty
Intracept
Sacro-Iliac Joint (SIJ) Fusion
Far Lateral Diskectomy
Coflex
Complex, will code later. Lets discuss.
Craniotomy Codes
Other
Will this operation be staged?
No, the operation will NOT be staged
Yes, the operation will be staged
Stage 1:
ALIF
LLIF
Posterior procedure (PLF, Lami, TLIF)
Other
Stage 2:
ALIF
LLIF
Posterior procedure (PLF, Lami, TLIF)
Other
Stage 3:
ALIF
LLIF
Posterior procedure (PLF, Lami, TLIF)
NA
Other
Will any modifiers be needed (besides -59)?
-51: Same day modifier, multiple procedures. 100% for 1st stand alone code and 50% for subsequent stand alone codes.
-58: Global modifier; Planned staged/related procedure; No $ reduction; New Global starts; *Mention staged/planned in BOTH op notes, but 2nd op note is mandatory).
-59: Same Day modifier; Distinct Service; 100% if add-on; 50% if stand alone.
-62: Surg Role Mod; Two surgeons c diff specialties; 125% paid, 62.5% to each. Each surgeon dictates and refers to others note.
-80: Surg Role Mod; Assist Surg; 100% to primary surgeon & 16% for surgical assist.
ALIF:
22558-62: Disk & Arthrodesis/fusion, 1st level, w/ Co-Surg (Vasc Surg uses 22558-62)
+22585-62: Disk & Arthroplasty/fusion, 2nd level, w/Co-Surg (Vasc Surg uses +22585-62)
-----------------
+22845-59: Plate, 1st level (Vasc Surg uses +22845-59,80)
+22845-59: Plate, 2st level( Vasc Surg uses +22845-59,80
-----------------
+22853: Cage #1 (Vasc Surg uses +22853-80)
+22853-59: Cage #2 (Vasc Surg uses +22853-80)
Other
Craniotomy Codes:
Tumor: Supra-Tentorial, Intra-axial (61510)
Tumor: Supra-Tentorial, Meningioma (61512)
Tumor: Infra-Tentorial, Intra-axial (61518)
Tumor: Infra-Tentorial, Meningioma (61519)
Tumor: Bone Tumor (61500)
Biopsy: Brain (61140)
Cyst Aspiration: Brain (61150)
Abscess Aspiration: Brain (61150)
Chiari Decompression (61343)
SDH, Burrhole, Unilateral (61154)
SDH, Burrhole, Bilateral (61154-50)
Crani, SDH/EDH, Supra-Tentorial (61312)
Crani, SDH/EDH, Infra-Tentorial (61314)
Crani, ICH, Supra-Tentorial (61313)
Crani, ICH, Infra-Tentorial (31315)
Depressed Skull Fracture - Extradural (62005)
Depressed Skull Fracture - Intradural (62010)
Decompressive Crani (61322)
SubQ Bone Flap (61316)
Cranioplasty
Cranioplasty >5cm (62141)
Retrieval of Bone Flap (62148)
Replacement of Bone Flap (62143)
NeuroNav: Intra-Dural (61781)
Neuro-Nav: Extra-Dural (61782)
Clinical: Shunt Tap (61070)
Clinical: Shunt Programming (62252)
Clinical: Lumbar Drain (62272)
Clinical: Closed Tx of Vertebral fracture w/o manipulation, but with bracing (22310)
EVD-Twist Drill (61107)
SEPS Drain (61108)
Type option 4
Lumbar TDR:
22857: First level
22860: Second level
Sacro-Iliac Joint (SIJ) Fusion with SI-Bone i-Fuse Implants:
27279
LLIF:
22558: Disk & Arthrodesis/fusion, 1st level
+22585: Disk & Arthroplasty/fusion, 2nd level
+22585: Disk & Arthroplasty/fusion, 3nd level
-----------------
+22845-59: Plate, 1st level
+22845-59: Plate, 2st level
+22845-59: Plate, 3st level
-----------------
+22853: Cage #1
+22853-59: Cage #2
+22853-59: Cage #3
Other
TLIF:
22633: Arthrodesis/fusion w/ PLF, 1st Level
22634: Arthrodesis/fusion w/ PLF, 2nd Level
-----------------
+22840: Instrumentaton, non-segmental
+22842: Instrumentation, segmental
-----------------
+22853: Cage
+22853-59: Cage, add'l
-----------------
+20930: Allograft
+20936: Autograft
-----------------
+61783: Spinal NeuroNavigation (Robot, O-Arm w/ Nav)
-----------------
Other
Postero-Lateral Fusion (PLF):
22612: Postero-Lateral Fusion, 1st level
+22614: Postero-Lateral Fusion, add'l level
+22614: Postero-Lateral Fusion, add'l level
+22614: Postero-Lateral Fusion, add'l level
+22614: Postero-Lateral Fusion, add'l level
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22633: Diskectomy (drop 22612)
------------------
+22840: Non-segmental fusion
+22842: Segmental fusion
------------------
+20930: Allograft
+20936: Autograft
------------------
+61783: Spinal Neuro-Nav (Robot or O-arm w/ nav)
Other
Coflex:
22867: 1st Level
22868: 2nd Level
Intracept (1st Segment):
64628: 1st Segment (i.e. 2 vertebral bodies)
Intracept (Add'l Segments):
64629x1: One Add'l Segment (i.e. 3 total vertebral bodies)
64629x2: Two Add'l Segment (i.e. 4 total vertebral bodies)
Far Lateral Diskectomy:
63056: Far Lateral Diskectomy
Other
Kyphoplasty:
22513: Thoracic Kyphoplasty, 1st Level
22514: Lumbar Kyphoplasty, 1st Level
**Select only one**
-----------------
22515: Kyphoplasty, T or L, 2nd Level
22515-59: Kyphoplasty, T or L, 3rd Level
22515-59: Kyphoplasty, T or L, 4rd Level
Other
Thoracic Laminectomy:
63046: 1st Level
63048: 2nd Level
63048-59: 3rd Level
63048-59: 4th Level
63048-59: 5th Level
-----------------
63266: Thoracic Lami for EDH
Other
Microdiskectomy:
63030: Microdisk, 1st level
63030-59: Microdisk, 2nd Level
-----------------
63042: Re-exploration Microdiskectomy, 1st Level
63044: Re-exploration Microdiskectomy, 2nd Level
Other
Lumbar Laminectomy:
63047: 1st Level
63048: 2nd Level
63048-59: 3rd Level
63048-59: 4th Level
63048-59: 5th Level
-----------------
63267: Lami for non-neoplasm (includes all levels!)
-----------------
*No Re-exploration code for Lami, just code as new lami.
Other
Spinal Cord Stimulation (SCS):
63650: Lead (first), Trial or Perm
63650-59: Lead (second), Trial or Perm
63650-59: Lead (third), Trial or Perm
63650-59: Lead (fourth), Trial or Perm
63663: Lead Revision/Replacement
63661: Lead Removal
-----------------
63655: Paddle Implant
63664: Paddle Revision/Replacement
63662: Paddle Removal
-----------------
63685: Generator Implant/Exchange
63688: Generator Revision/Removal
Posterior Cervical Fusion:
22600: Fusion/Arthrodesis, 1st Level
22614:Fusion/Arthrodesis, 2nd Level
22614:Fusion/Arthrodesis, 3rd Level
22614:Fusion/Arthrodesis, 4th Level
22614:Fusion/Arthrodesis, 5th Level
22614:Fusion/Arthrodesis, 6th Level
-----------------
22840: Non-Segmental Instrumention
22842: Segmental Instrumentation, 3-6 Segments
22843: Segmental Instrumentation, 7-12 Segments
-----------------
+20930: Allograft
+20936: Autograft
-----------------
61783: NeuroNav Spinal
22326: ORIF, Cervical (Jumped Facets)
22830: Exploration of Fusion
63265: Lami for Cervical EDH
Other
Posterior Cervical Laminectomy:
63045: 1st Level
63048: 2nd Level
63048: 3rd Level
63048: 4th Level
63048: 5th Level
63048: 6th Level
Other
Cervical Corpectomy, 1 level:
63081: Corpectomy, 1st level
22554-51 (same day modifier): Upper end plate preparation
+22585: Lower end plate preparation
+22845-59: Plate for single level corpectomy
+22854: Corpectomy Cage
+69990: Microscopic microdissection
+20936: Allograft
Cervical Corpectomy, 2 level:
63081: Corpectomy, 1st level
+63082: : Corpectomy, 2nd level
22554-51 (same day modifier): Upper end plate preparation
+22585: Lower end plate preparation
+22846-59: Plate for two level corpectomy
+22854: Corpectomy Cage
+69990: Microscopic microdissection
+20936: Allograft
Cervical Corpectomy, 1 level w/ Adj ACDF:
63081: Corpectomy, 1st level
22551-59: ACDF, 1st level
22554-51 (same day modifier): Upper end plate preparation
+22585: Lower end plate preparation
+22846-59: Plate for corpectomy & ACDF
+22854: Corpectomy Cage
+22853: ACDF Cage
+69990: Microscopic microdissection
+20936: Allograft
Cervical Corpectomy "Hybrid" (Two Level ACDF=ACDF + Corp):
63081: Corpectomy, 1st level
22551-59: ACDF, 1st level
22554-51 (same day modifier): Upper end plate preparation
+22585: Lower end plate preparation
+22845-59: Plate for "corpectomy" & ACDF (2 level plate)
+22854-59: Corpectomy Cage
+22853: ACDF Cage
+69990: Microscopic microdissection
+20936: Allograft
Odontoid Screw:
22319: Odontoid screw
ACDA:
22856: 1st level
22858: 2nd level
ACDF:
22551: Diskectomy and Fusion, 1st level
+22552: Diskectomy and Fusion, 2nd level
+22552: Diskectomy and Fusion, 3rd level
+22552: Diskectomy and Fusion, 4th level
+22552: Diskectomy and Fusion, 5th level
----------------------
+22845: Plate, 1-2 levels
+22846: Plate, 3+ levels
----------------------
+22853: PEEK Cage, 1st Level
+22853: PEEK Cage, 2nd Level
+22853: PEEK Cage, 3rdt Level
+22853: PEEK Cage, 4th Level
+22853: PEEK Cage, 5th Level
----------------------
+20936: Autograft
+20930: Allograft
----------------------
21501: Evacuation of hematoma or infection
22830: Exploration of fusion
22326: ORIF, Cervical (jumped facets)
22855: Removal of anterior instrumentation.
Other
Posterior Add on Codes:
+61783:Spinal NeuroNavigation (Robot, O-Arm w/ Nav)
63046: Laminectomy, THORACIC, 1st level
63047: Laminectomy, Lumbar, 1st level
+63048: Laminectomy, 2nd level
+63048-59, add'l level
+63048-59, add'l level
+63048-59, add'l level
63056: Far lateral diskectomy
63267: Lami for non-neoplasm (i.e. syn cyst or abscess) *incl all levels!
+22614: Postero-Lateral Fusion, Lumbar, add'l level
+22614-59: Postero-Lateral Fusion, add'l level
+22614-59: Postero-Lateral Fusion, add'l level
22850: Removal of non-segmental instrumentation
22852: Removal of segmental instrumentation
22830: Exploration of fusion
22327: ORIF, Thoracic
22325: ORIF, Lumbar
+63052: Lami at same site as TLIF, 1st level
+63053: Lami at same site as TLIF, 2nd level
22610: Postero-Lateral fusion, Thoracic, 1st level
Other
Notes:
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