The Business of Spine Coding Handbook For Spine Surgery 2015

The Business of Spine Coding Handbook For Spine Surgery 2015 1

The following Coding Concept Resource is not to be considered a replacement for the Current Procedural Terminology (CPT) book or the International Classification of Diseases 9 th Revision- Clinical Modification (ICD-9-CM) book. It is designed simply as a resource to help you get a handle on it. Always refer back to the full Current Procedural Terminology (CPT) book when coding. Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listing are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. International Classification of Diseases 9 th Revision-Clinical Modification (ICD-9-CM) is copyright 2014 OptumCoding. All Rights Reserved. 2

Table of Contents Procedural Codes DECOMPRESSION CODES... Anterior Decompression... Discectomy... Transoral Approach.. Corpectomy... Corpectomy for Lesion... Posterior Decompression... Laminotomy/Discectomy... Laminoplasty... Laminectomy... Laminectomy for Excision of Lesion other than Herniated Disk... Extracavitary Decompression... Lateral Extracavitary Approach for Extradural Exploration/Decompression... DURAL REPAIR.... ARTHROPLASTY... FUSION CODES... Anterior Fusion... Posterior Fusion... Extracavitary Fusion... Exploration of Fusion... Pre-Sacral Fusion... Instrumentation... 10 Anterior... 10 Posterior... 10 Interbody Implants (Anterior or Posterior)... 10 Removal/Reinsertion (Anterior or Posterior)... 10 Bone Grafts... 10 Bone Marrow Aspiration... 11 SPINAL DEFORMITY... 11 Intraspinous/Intrafacet Procedures... 12 OSTEOTOMY/EXCISION OF BONE... 12 Excision... 12 Osteotomy... 13 MISCELLANEOUS CODES... 13 Fracture... 13 Tongs/Halo... 13 Vertebroplasty... 13 Kyphoplasty... 13 Annuloplasty... 14 Incision & Drainage... 14 Infection... 14 Biopsy... 14 Neurostimulators... 15 Bone Growth Stimulators... 15 Imaging... 15 Unspecified Procedure Code... 15 Appendix A: Modifiers 16 Appendix B: Category III Codes: T Codes 17 Appendix C: Diagnosis Codes 19 Appendix D: Terminology 24 4 4 4 4 4 4 5 5 5 6 7 8 8 8 8 9 9 9 9 9 9 10 3

Procedural Codes DECOMPRESSION CODES Anterior Decompression Discectomy 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace (Do not report 63075 in conjunction with 22554, even if performed by separate providers. To report anterior cervical discectomy and interbody fusion at the same level during the same session use 22551.) +63076 Cervical, each additional interspace (Do not report 63076 in conjunction with 22554, even if performed by separate providers. To report anterior cervical discectomy and interbody fusion at the same level during the same session use 22552.)Use 63076 in conjunction with 63075 63077 Discectomy, anterior, thoracic, single interspace +63078 Thoracic, each additional interspace. Transoral Approach 61575 Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion 61576 Requiring splitting of tongue and/or mandible (including tracheostomy) Corpectomy for Spinal Condition 63081 Vertebral corpectomy (vertebral body resection), cervical, single segment. Partial or complete corpectomy, with decompression of spinal cord and/or nerve root(s) +63082 Cervical, each additional segment 63085 Vertebral corpectomy (vertebral body resection), thoracic, single segment +63086 Thoracic, each additional segment 63087 Vertebral corpectomy (vertebral body resection), thoracolumbar approach, lower thoracic or lumbar, single segment +63088 Each additional segment 63090 Vertebral corpectomy (vertebral body resection), transperitoneal or retroperitoneal approach, lower thoracic, lumbar or sacral, single segment +63091 Each additional segment Corpectomy for Intraspinal Lesion 63300 Vertebral corpectomy (vertebral body resection), extradural, cervical, single segment. Partial or complete corpectomy for excision of intraspinal lesion 63301 Extradural, thoracic, by transthoracic approach, single segment 63302 Extradural, thoracic, by thoracolumbar approach, single segment 63303 Extradural, lumbar or sacral by transperitoneal or retroperitoneal approach, single segment +63308 Each additional segment 63304 Vertebral corpectomy (vertebral body resection), intradural, cervical, single segment 63305 Intradural, thoracic by transthoracic approach, single segment 63306 Intradural, thoracic by thoracolumbar approach, single segment 63307 Intradural, lumbar or sacral by transperitoneal or retroperitoneal approach, single segment +63308 Each additional segment 4

Posterior Decompression Laminotomy/Discectomy 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar +63035 Each additional interspace, cervical or lumbar 0274T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic 0275T Lumbar 63040 Laminotomy, (hemilaminectomy), re-exploration, cervical (unilateral), single interspace, with decompression of nerve root, including partial facetectomy, foraminotomy and/or discectomy +63043 Each additional interspace, cervical 63042 Laminotomy, (hemilaminectomy), re-exploration, lumbar, (unilateral), one interspace. +63044 Each additional interspace, lumbar 63055 Transpedicular approach, thoracic, single segment, with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc). 63056 Transpedicular lumbar, single segment, including transfacet or lateral extraforaminal approach. (e.g. herniated intervertebral disc) +63057 Each additional segment, thoracic or lumbar 63064 Costovertebral approach, thoracic, single segment, with decompression of spinal cord or nerve root(s), (e.g., herniated intervertebral disk) +63066 Each additional segment Laminoplasty 63050 Laminoplasty, cervical, two or more vertebral segments, with decompression of the spinal cord 63051 Laminoplasty, cervical, with reconstruction of the posterior bony elements, including the application of bridging bone graft and non-segmental fixation devices (e.g., wire, suture, miniplates), when performed 5

Laminectomy 63001 Laminectomy, cervical, one or two vertebral segments, with exploration and/or decompression of spinal cord and/or cauda equina, but without facetectomy, foraminotomy or discectomy, (spinal stenosis) 63003 Thoracic, one or two vertebral segments 63005 Lumbar, one or two vertebral segments, except for spondylolisthesis 63011 Sacral 63012 Laminectomy, lumbar (Gill type procedure), with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve root for spondylolisthesis 63015 Laminectomy, cervical, more than two segments, with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (spinal stenosis) 63016 Thoracic, more than two segments 63017 Lumbar, more than two segments 63045 Laminectomy, cervical, single segment, including facetectomy and foraminotomy (unilateral or bilateral) with decompression of spinal cord, cauda equina and/or nerve roots(s), (e.g., Spinal or lateral recess stenosis). 63046 Thoracic, single vertebral segment. 63047 Lumbar, single vertebral segment. +63048 Each additional segment: cervical, thoracic or lumbar. 6

Laminectomy for Excision of Lesion other than Herniated Disk 63250 Laminectomy, cervical, for excision of occlusion of arteriovenous malformation of spinal cord 63251 Thoracic 63252 Thoracolumbar 63265 Laminectomy, extradural, cervical, for excision or evacuation of intraspinal lesion other than neoplasm 63266 Thoracic 63267 Lumbar 63268 Sacral 63270 Laminectomy, intradural, cervical, for excision of intraspinal lesion other than neoplasm 63271 Thoracic 63272 Lumbar 63273 Sacral 63275 Laminectomy, extradural, cervical, for biopsy/excision of intraspinal neoplasm 63276 Thoracic 63277 Lumbar 63278 Sacral 63280 Extramedullary, intradural, cervical 63281 Thoracic 63282 Lumbar 63283 Sacral 63285 Intramedullary, intradural, cervical 63286 Thoracic 63287 Thoracolumbar 63290 Combined extradural-intradural lesion, any level. + 63295 Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure 7

Lateral Extracavitary Decompression Lateral Extracavitary Approach for Extradural Exploration/Decompression 63101 Vertebral corpectomy thoracic, lateral extracavitary approach, partial or complete corpectomy with decompression of spinal cord and/or nerve root(s) (e.g., for tumor or retropulsed bone fragments), single segment 63102 Lumbar, single segment +63103 Thoracic or lumbar, each additional segment Dural Repair 63707 63709 63710 Repair of dural/celebrospinal fluid leak, not requiring laminectomy With laminectomy Dural graft, spinal Arthroplasty-Artificial Disc 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); cervical, single interspace +22858 Second level; cervical +0375T Cervical; three or more levels 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace; lumbar, single interspace +0163T each additional interspace, lumbar 22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach; cervical, single interspace +0098T each additional interspace, cervical 22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach; lumbar, single interspace +0165T each additional interspace, lumbar 22864 Removal of total disc arthroplasty (artificial disc), anterior approach; cervical, single interspace. +0095T each additional interspace, cervical 22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar +0164T each additional interspace, lumbar 0202T Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine 8

FUSION CODES Anterior Fusion 22548 Arthrodesis, C1-C2 (atlas-axis), anterior transoral or extraoral technique, with or without excision of odontoid process 22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 +22552 cervical below C2, each additional interspace 22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 22556 Thoracic 22558 Lumbar +22585 Each additional interspace Posterior Fusion 22590 Arthrodesis, craniocervical, posterior technique 22595 Arthrodesis, C1-C2, posterior 22600 Arthrodesis, cervical below C2, posterior or posterolateral, single level 22610 Thoracic, with lateral transverse technique, when performed 22612 Lumbar, with lateral transverse technique, when performed +22614 Each additional vertebral segment 22630 Arthrodesis, lumbar, posterior interbody technique, single interspace, including laminectomy and/or discectomy to prepare interspace (other than for decompression) +22632 Each additional interspace 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy (other than for decompression), single interspace, and segment; lumbar +22634 Each additional interspace and segment, lumbar Lateral Extracavitary Fusion 22532 Arthrodesis, thoracic, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression). 22533 Lumbar +22534 Thoracic or lumbar, each additional vertebral segment Exploration of Fusion 22830 Exploration of spinal fusion Pre-Sacral Fusion 22586 Pre-sacral interbody fusion with posterior instrumentation, L5-S1 interspace +0309T L4-L5 interspace 0195T +0196T L4-L5 Pre-sacral interbody fusion, without instrumentation, L5-S1 interspace 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive, with image guidance, includes obtaining bone graft when performed and placement of transfixing device. 27280 Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed. 9

INSTRUMENTATION Anterior +22845 Anterior instrumentation, 2-3 vertebral segments +22846 4 to 7 vertebral segments +22847 8 or more vertebral segments Posterior +22840 Posterior non-segmental instrumentation. (e.g., single Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) +22841 Internal fixation by wiring of spinous processes +22842 Posterior segmental instrumentation, 3 to 6 segments. (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires) +22843 7 to 12 vertebral segments +22844 +22848 13 or more vertebral segments Pelvic fixation other than sacrum Interbody Implants (Anterior or Posterior) +22851 Application of intervertebral biomechanical device(s) (e.g., synthetic cages(s), methylmethacrylate) to vertebral defect or interspace. (List separately in addition to code for primary procedure) Removal/Reinsertion (Anterior or Posterior) 22849 Reinsertion of spinal fixation device 22850 Removal of posterior non-segmental instrumentation 22852 Removal of posterior segmental instrumentation; e.g. pedicle screws at several levels 22855 Removal of anterior instrumentation Bone Grafts +20930 Allograft: morselized or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) +20931 Allograft: structural, for spine surgery only (List separately in addition to code for primary procedure) +20936 Autograft: (includes harvesting the graft); local (ribs, spinous process, or laminar fragments); obtained from same incision +20937 Autograft: Morselized, through separate skin or fascial incision +20938 Autograft: Structural Bicortical or tricortical (through separate skin or fascial incision) Bone Marrow Aspiration 38220 Bone marrow, aspiration only 10

Spinal Deformity 22800 Arthrodesis, posterior for spinal deformity, up to 6 vertebral segments, with or without cast 22802 7 to 12 vertebral segments 22804 13 or more vertebral segments 22808 Arthrodesis, anterior for spinal deformity, 2 to 3 vertebral segments, with or without cast 22810 4 to 7 vertebral segments 22812 8 or more segments 22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segments(s) (including body and posterior elements); single or 2 segments 22819 3 or more segments Intraspinous/Intrafacet Procedures 0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices(s) single level; cervical 0220T Thoracic 0221T Lumbar +0222T Each additional vertebral segment 0171T Insertion of posterior spinous process distraction device; lumbar; single level +0172T Each additional level 11

OSTEOTOMY/EXCISION OF BONE Excision for Intrinsic Bony Lesion 22100 Partial excision of posterior vertebral component (e.g., spinous process, lamina or facet), cervical, single vertebral segment 22101 Thoracic 22102 Lumbar +22103 Each additional segment 22110 Partial excision of vertebral body, cervical, single vertebral segment, without decompression of spinal cord or nerve root(s) 22112 Thoracic 22114 Lumbar +22116 Each additional segment Osteotomy 22206 Osteotomy of spine, posterior or posterolateral approach, three columns, (e.g., PSO) thoracic, one vertebral segment 22207 Lumbar +22208 Each additional segment 22210 Osteotomy of spine, posterior or posterolateral approach, (e.g. Smith Peterson) cervical, one vertebral segment 22212 Thoracic 22214 Lumbar +22216 Each additional segment 22220 Osteotomy of spine, including discectomy, anterior approach, (e.g. Smith Peterson) cervical, single vertebral segment 22222 Thoracic 22224 Lumbar +22226 Each additional segment 12

Miscellaneous Fracture 22305 Closed treatment of vertebral process fracture 22310 Closed treatment of vertebral body fracture w/o manipulation requiring casting or bracing 22315 Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction 22318 22319 22325 22326 22327 +22328 Open treatment and/or reduction of odontoid fracture(s) and/or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting With grafting Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar Cervical Thoracic Each additional fractured vertebra or dislocated segment Tongs/Halo 20660 Application of cranial tongs, caliper or stereotactic frame, including removal 20661 Application of halo, including removal; cranial Vertebroplasty: Vertebral Body, Embolization or Injection 22510 Percutaneous vertebroplasty (bone biopsy included when performed), one vertebral body, unilateral or bilateral injection; inclusive of all imaging guidance; cervicothoracic 22511 lumbosacral +22512 Each additional cervicothoracic or lumbosacral vertebral body Kyphoplasty 22513 Percutaneous vertebral augmentation, including cavity creation using mechanical device, one vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic 22514 lumbar +22515 Each additional thoracic or lumbar vertebral body 13

Annuloplasty 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral, including fluoroscopic guidance; single level +22527 One or more additional levels Incision and Drainage 22010 Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic 22015 lumbar, sacral, or lumbosacral Infection 10180 Incision and drainage, complex, postoperative wound infection Biopsy 20200 20205 20206 20220 20225 20240 20245 20250 20251 Biopsy, muscle; superficial deep percutaneous needle Biopsy, bone, trocar, or needle: superficial (eg, spinous process, ribs, femur) deep (eg, vertebral body, femur) Biopsy bone, open; superficial (eg, ilium, sternum, spinous process,) deep (eg, humerus, ischium, vertebral body, femur) Biopsy, vertebral body, open; thoracic cervical or lumbar Neurostimulators 63650 63655 63661 63662 63663 Percutaneous implantation of neurostimulator electrode array, epidural Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Revision, including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63664 63685 63688 0282T 0283T 0284T 0285T Revision including replacement of spinal neurostimulator electrode plate/paddles(s) placed via laminotomy or laminectomy, including fluoroscopy Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Revision or removal of implanted spinal neurostimulator pulse generator or receiver Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous, cervical, thoracic or lumbar, for trial, including removal at the conclusion of trial period Permanent, implantation of neurostimulator with implantation of a pulse generator Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed 14

Bone Growth Stimulators 20974 20975 20680 Imaging Electric stimulation to aide in bone healing; Non Invasive Invasive (operative) Removal of implant, deep (e.g., buried wire, pin screw, metal band and, nail, rod or plate) 69990 76000 61783 Microsurgical techniques, requiring use of operating microscope Fluoroscope; up to 1 hour physician time Stereotactics Unspecified Procedure Codes 64999 Unlisted procedure, nervous system 22899 Unlisted procedure, spine 15

Appendix A: Modifiers 22 Increased Procedural Services: When the service(s) provided is greater than that usually provided for the listed procedure, it may be identified by adding a modifier 22 to the usual procedure code. A report may also be appropriate. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding a modifier 50 to the appropriate code. 51 Multiple Procedures: When multiple procedures, other than E/M services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). 52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced. 53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. 59 Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. 62 Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. 80/82 Assistant Surgeons: Surgical assistant services may be identified by adding modifier 80 or 82 to the usual procedure number(s). Use 82 modifier if a residency program is in place or 80 modifier if there is no residency program in place. 16

Appendix B: Category III Codes: T-Codes 0171T +0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace; cervical. (List separately in addition to code for primary procedure) +0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace; cervical +0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar. +0164T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar. +0165T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace; lumbar. Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level +0172T each additional level. 0195T 0196T 0200T 0201T 0202T 0219T 0220T 0221T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed: L5-S1 interspace L4-L5 interspace Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices(s) single level; cervical thoracic lumbar +0222T each additional vertebral segment 0274T 0275T 0282T 0283T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic lumbar Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period permanent, with implantation of a pulse generator 17

0284T 0285T Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed +0309T Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace 0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); cervical, 3 or more levels 18

Appendix C: Diagnosis Codes Late Effects of Infectious and Parasitic Diseases 139.8 Late effects of other and unspecified infectious and parasitic diseases Neoplasms 170.2 170.6 192.2 192.9 198.4 198.5 Malignant neoplasm of bone and articular cartilage; Vertebral column, excluding sacrum and coccyx Malignant neoplasm of bone and articular cartilage; sacrum and coccyx Malignant neoplasm of Spinal Cord Malignant neoplasm of other specified sites of the nervous system Secondary malignant neoplasm of other parts of nervous system Secondary malignant neoplasm of bone and bone marrow 198.89 Secondary malignant neoplasm of other specified sites 213.2 213.6 Benign neoplasm of bone and articular cartilage; vertebral column, excluding sacrum and coccyx Benign neoplasm of bone and articular cartilage; pelvic bones, sacrum and coccyx 238.0 Neoplasm of uncertain behavior of bone and articular cartilage 238.8 Neoplasm of uncertain behavior of other specified sites 239.2 Neoplasms on unspecified nature; Bone soft tissue and skin 239.8 Neoplasms on unspecified nature; Other specified sites 239.9 Neoplasms on unspecified nature; Site unspecified Instability 718.88 Instability, other joint derangement, not elsewhere classified, other specified sites NEC 719.90 Other and unspecified disorders of joint; site unspecified 724.6 Other and unspecified disorders of back; Instability, lumbosacral; disorders of the sacrum Spondylosis 721.0 Cervical Spondylosis without Myelopathy 721.1 Cervical Spondylosis with Myelopathy 721.2 Thoracic Spondylosis without Myelopathy 721.3 Lumbar Spondylosis without Myelopathy 721.4 Thoracic or Lumbar Spondylosis with Myelopathy 721.41 Thoracic region 721.42 Lumbar region 721.90 Spondylosis of unspecified site, without mention of Myelopathy 721.91 Spondylosis of unspecified site, with mention of Myelopathy 19

Displacement/Herniation 722.0 Displacement of cervical intervertebral disc without Myelopathy 722.10 Displacement of Lumbar intervertebral disc without Myelopathy 722.11 Displacement of Thoracic intervertebral disc without Myelopathy 722.2 Displacement of intervertebral disc, site unspecified without myelopathy 722.6 Degeneration of intervertebral disc, site unspecified 722.71 Intervertebral disc disorder with Myelopathy; cervical region 722.72 Intervertebral disc disorder with Myelopathy; thoracic region 722.73 Intervertebral disc disorder with Myelopathy; lumbar region Degenerative/Degeneration 722.4 Degeneration of cervical intervertebral disc; degenerative disc disease 722.51 Degeneration of thoracic or thoracolumbar degenerative disc disease 722.52 Degeneration of lumbar or lumbosacral degenerative disc disease Postlaminectomy Syndrome 722.81 Postlaminectomy syndrome, cervical region 722.82 Postlaminectomy syndrome, thoracic region 722.83 Postlaminectomy syndrome, lumbar region Disc Disorder 722.91 Other and unspecified disc disorder; cervical region 722.92 Other and unspecified disc disorder; thoracic region 722.93 Other and unspecified disc disorder; lumbar region Stenosis 723.0 Spinal Stenosis in cervical region 724.01 Spinal Stenosis in thoracic region 724.02 Spinal Stenosis in lumbar region 20

Radiculitis/Radiculopathy 723.4 Brachial neuritis or radiculitis NOS, cervical 729.2 Neuralgia, neuritis, radiculitis, unspecified Pain & Radiculitis 723.1 Cervicalgia; pain cervical spine 723.4 Brachial neuritis or radiculitis NOS 723.7 Ossification of posterior longitudinal ligament in cervical region 724.1 Pain in the thoracic spine 724.2 Lumbago; lumbar pain 724.3 Sciatica 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 724.5 Backache, unspecified 724.6 Disorders of sacrum 727.40 Synovial cyst, unspecified 728.5 Hypermobility syndrome 729.0 Rheumatism, unspecified and fibrositis 729.1 Myalgia and myositis, unspecified Disorders 733.00 Osteoporosis 733.20 Cyst of bone (localized); unspecified 21

Fractures 733.10 Pathologic fracture; unspecified site 733.13 Pathologic fracture of vertebrae 733.81 Malunion of fracture 733.82 Non-union of fracture; pseudoarthrosis 805.0 Fracture of vertebral column without mention of spinal cord injury, cervical level, unspecified level 805.1 Cervical, open *** For 805.0 & 805.1, you must add the 5th digit which is the level at which the fracture has been noted; for example, closed fracture at C4 = 805.04*** 805.2 Dorsal [Thoracic], closed 805.3 Dorsal [Thoracic], open 805.4 Lumbar, closed 805.5 Lumbar, open 805.6 Sacrum and coccyx, closed 805.7 Sacrum and coccyx, open 805.8 805.9 Unspecified, closed Unspecified, open Kyphosis 737.0 Adolescent postural kyphosis 737.10 Kyphosis (acquired) (postural) 737.11 Kyphosis due to radiation 737.12 Kyphosis, postlaminectomy 737.19 Other 737.20 Lordosis (acquired) (postural) Scoliosis 737.30 Scoliosis (and kyphoscoliosis), idiopathic 737.39 Other 737.40 Curvature of spine, unspecified 737.41 Kyphosis 737.8 737.9 Other curvatures of spine Unspecified curvature of spine 22

Spondylolisthesis 738.4 Acquired Spondylolisthesis 756.11 Spondylolysis, lumbosacral region 756.12 Spondylolisthesis 756.13 Absence of vertebra, congenital Sprain/Strain 846.0 Sprain/strain of lumbosacral 847.0 Sprain/strain of neck 847.1 Sprain/strain of thoracic 847.2 Sprain/strain of lumbar Post-Op 996.4 Mechanical Complication of internal orthopedic device, implant, and graft 996.59 Mechanical complication of other specified prosthetic device, implant or graft due to other implant and internal device, not elsewhere classified 996.67 Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft 998.32 Disruption of external operation wound 998.51 Infected postoperative seroma 998.59 Other postoperative infection 998.83 Non-healing surgical wound V45.4 Arthrodesis status V45.89 Post-surgical status, other 23

Appendix D: Terminology A vertebral segment describes the basic constituent part into which the spine is divided. It represents a single complete vertebral bone with its associated articular processes and laminae. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies which contain the intervertebral disc and the nucleus pulposus, annulus fibrosus and two cartilagenous endplates. Segmental instrumentation is defined as fixation at each end of the construct and at least one additional interposed bony attachment. Non-segmental instrumentation is defined as fixation at each end of the construct and may span several vertebral segments without attachment of the intervening segments. 24