All right, everyone, this is going to be part three, and we're going to complete the cervical module with this episode of our cervical-based coding, and thereby complete our one hour of CME at the same time. My disclosures, again, have remained unchanged throughout this entire series. This is our second day in clinic, so we did very straightforward cases using ICD-10 codes and CPT, and we're going to incorporate some trauma now, and many of us do manage trauma, and it's important to be able to recognize that there are some nuances to ICD-10 coding for that, and covering situations like corpectomy, more complex situations like patients with previous surgery where we have to explant a plate, and maybe even have to remove a plate and do levels above and below. So we're going to cover some of those things. The topics are going to include corpectomy, postures, decompression, and infusion, in the case of a central cord, management of adjacent segment, and anterior-posterior decompression and infusion. Again, the hope is that with these three episodes of the cervical coding webinar, we can cover the majority of circumstances you will be running into as far as your coding. This, again, represents the more complex of the levels. Again, we're reviewing radiculopathy, myelopathy, stenosis, and spondylosis. Let's start with a corpectomy, because there are nuances to coding a corpectomy very different than just doing the ACDF. So 19-year-old man in a rollover motor vehicle accident, incomplete spinal cord injury, anti-gravity in the lower extremities, decreased hand intrinsics. He's got a systolic blood pressure of 80 millimeters of mercury, and there is his CT scan. That's a problem. So this is a case that, obviously, we're all going to take immediately for intervention. The ICD-10 code, obviously, we're not worried about that at first, but eventually we do have to get to coding this. So ICD-10 Chapter 19 is going to be the chapter entitled Injury, Poisoning, and Other Consequences of External Causes. The Chapter 19, beginning with the letter S, has a series of all of these trauma codes. S-12 is a fracture of the cervical vertebrae. We can drill that down even more specific, and we can get to the C7 burst fracture. And so this is going to be the various categories, S-12, TAC-6, and 9. It's going to be displaced, non-displaced, and then whether it's the initial encounter, ABD, GKS. This is obviously a burst-type fracture. And so what we would be, and this is our first time seeing him, and so while we're getting him to the OR, we at least know that we're doing S-12, TAC-690, Alpha is our ICD-10. There's also, in Chapter 20, the External Causes of Morbidity. Beginning with the letter V, you can get V-86, Occupant of a Special All-Terrain Vehicle or Off-the-Road Vehicle, and even designate whether it's a passenger, driver, traffic accident, or non-traffic accident. That sort of granularity is remarkable, considering that we cannot get the granularity of a adjacent segment. It's not an ICD-10 code, but in this case, it would be V, Victor, 86, TAC-59, and that is the driver of an all-terrain vehicle, whether it's a dirt bike, go-kart, golf cart, non-traffic in a non-traffic accident. So there you have it. What is the procedure that we're going to do? I think we can have universal agreement that, at the minimum, we're going to be doing a corpectomy and possibly even backing this up with posterior instrumentation, but in this case, it's an anterior approach from C-6 to T-1, did a complete corpectomy by criteria. You have to remove greater than 50% of the vertebral body for it to meet criteria for a corpectomy. People will say, well, I removed more than that for a corpectomy, but the reality is is that we have encountered a corpectomy code coming under increasing scrutiny. Why? We find ourselves looking at data that suggests that corpectomies may not be done, and individuals may misunderstand that they are removing the underside of a vertebral body to remove a large osteophyte on the level above and below, and they say, well, if I add up all the bone that I removed on the underside of C-5 and the superior abscess of C-6 to decompress a big osteophytic spur causing spinal cord compression, it's almost like doing a corpectomy. It's not. We have to remove it. In the purest sense, it is end plate to end plate, and that is the true spirit of a corpectomy. This is one of the circumstances where the operating microscope is not bundled into the CPT code, and so we would use the operating microscope 69990 preparation of the end plates because it's going to have its own orthodesis code. That's what we're doing. We're preparing the end plates on the underside of C-6 for orthodesis, superior aspect of T-1. Then we are placing, in this case, a peak interbody spacer with autograft, obviously everything that we harvested from within the same incision, and morselized, it all became morselized when we took it out, mixed with morselized allograft, and then placement of the anterior cervical plate looks something like this when we are done, and so how do we code it? Well, a corpectomy has a 63081 corpectomy code, and again, we are dictating. When I dictate this in the technique and detail, I say greater than 50%. As a matter of fact, I did about 80, if not 90% of the vertebral body was removed. I exposed the end plate on the underside of C-6 to the superior end plate of T-1. We can use the microscope code, you want to put that immediately after your 63081 so that you ensure that you get the appropriate reimbursement. It's not bundled to the 63081, 22554 with 51 modifier, orthodesis anterior technique at C-6-7, and then you can use, there's another orthodesis code, 22585. These are the Easter eggs that we get for working in a corpectomy, then the entry instrumentation code because it's up to three vertebral segments, so we're going from 6, imaginary 7, because that's gone, and then T-1. Then we, different from the other codes that we used previously, 22853 is for occupying a spatial, but we're going to put in a biomechanical spacer for corpectomy and orthodesis. We use the 22854 and, of course, the local autographed harvest. That is the main differentiator period. This is just the anatomy. When we talk about things going on a code, it's always interesting to see how things evolve. The 22851 used to cover all of these, and this is just more for historical purposes. In 2008, there was a screen. One of the fastest-growing procedures, this obviously had to do with the rise of the standalone interbody spacers. In 2011, it was designated a high-expenditure procedure, and so getting all that attention to it, it brought a survey to that. That's how we reconciled the attention, so in 2017, the 22851 was deleted, and it was replaced with the 22853 and the 22854. These are the CPT descriptors of those codes. If we do that, because the initial conception of 22851 was to address a void, a space created in taking out a tumor where you may put in methamethacrylate with diamond pins, and it would not be for orthodesis, which is why the 22859 is still more of the legacy of that code. How do we do this with our visual coding schema so we can understand where everything comes from? We took out the vertebral body of C7, and that's going to be 63081, and again, we can put the operating microscope code on that. We are putting in a peak spacer, so that's going to be the 22854, and then we get an orthodesis code for the interface of that peak spacer with the autograft in it on the underside of C6, so you get the 22554, put that 51 modifier on there, and 22585, and then you get the anterior cervical plate, so all of those codes are covered in there. The burst, C7 burst summary for coding this would be ICD-10 with the S12-TAC690-V8-6-TAC59 that captures the specificity of how the accident happened, and then our 63081 with the microscope code attached to that, the anterior orthodesis technique at C6-7 with the anterior orthodesis technique at C7-T1 interface, and then our plating and use of the spacer with the autograft. So, those are the codes on how we capture that case. Case 2 is cervical laminectomy with lateral mass fixation. We've got a 63-year-old right-hand dominant man who was in another rollover ATV accident. This is what we do in the desert out here. We get on, take these ATVs up sand dunes, and then surprise ourselves when the things roll over. 15-minute period, he was unable to move his upper and lower extremities. Now he's got burning dysestesias, no use of his hands. He's got decreased strength in the tricep, three out of five, but he's getting rapidly better, even though he's having upper extremity symptoms. He's got a congenitally narrow canal, and he obviously has a central cord. So his diagnosis is cervical stenosis with myelopathy. He does have a central cord syndrome, and the accident happened in an ATV. So for ICD-10, again, we go to Chapter 19, beginning with the letter S. We see our neurological injuries, and it's going to be S14, TAC1, complete or incomplete central cord lesion. You code to the highest level of the cervical lesion, and then obviously initial encounter, subsequent encounter. This is our first encounter. So we are going to code to the highest level. The central cord is at C3, coding to the highest level. It's our initial encounter. S14, TAC1, 2, 3, alpha, gets us there. Again, we're familiar with Victor 86, TAC59. We just used that in the other case we discussed earlier, and then we do a posterior approach in this case. He's got a congenitally narrow canal, and so it is going to be, and it's in the context of trauma. You could make an argument for laminoplasty, or in this case it was C3 to C6, trough laminectomies to remove what we call the lobster tail from C3 to C6, placement of lateral mass grooves, and then we do the arthrodesis decortication within the facet joints at C3, C4, C5, C6. So how do we, and this is how we treated this. So this is, we did not do, it's important to recognize, because hey, wait a second, what about the cervical laminectomy code? Well I didn't do, I did a trough laminectomy, I did not decompress the nerve root, I created a larger central canal. So I can only use a 63015, and then I'm using my arthrodesis at C3, 4, C4, 5, and C5, 6. So those are three arthrodesis codes. This is going to be posterior segmental instrumentation, three to six vertebral segments, and I went from C3 to C6, and then I obviously used my morcellized autograft, harvested from within the same incision, and morcellized autograft. So the trough laminectomies is captured by the 63015, and then the lateral mass, or segmental instrumentation is 22842, and then our arthrodesis. You're going to get an arthrodesis at each one of these, that's how we separate those out, 51 modifier, and that captures the codes. Obviously then we need our graft codes, autograft and allograft codes. Okay, so this is a summary of the central cord, C7 burst fracture, and then the ATV, and then our trough laminectomy's arthrodesis codes, so that you can see the rationale behind breaking it up. I always draw my boxes when I'm submitting my code so I make sure I'm not missing a code that may be of value when I submit my charges. What about an adjacent segment degeneration? Here's a 50-year-old right-hand dominant man, he's a bus driver, he had a 5-6 ACDF years ago, nine years prior, and his symptoms did well, but he's been having right radicular arm pain, and now he cannot find relief, he can't drive without doing the shoulder abduction sign on the bus, and it's worrying the parents who are taking their kids into that bus and see the bus driver with his right arm up over his head. So he does have right tricep weakness. He is a veteran of Iraq and Afghanistan, and so I bring that up because the guy is used to doing 100 push-ups a day, and now he can barely do a single push-up because of the tricep weakness, which means it's time to operate. He can bicep and tricep reflex on the right, positive spurling sign, shoulder abduction sign. Again, that's how he drives the bus. So there is his previous plate. This is one of the issues, and again, I know this is coding, but let's chat about the plate to this distance and risk factors for adjacent secondary degeneration. Anytime we put him on a plate, we always, and this is his imaging. You can see that he's got some foraminal narrowing affecting the exiting nerve root of C7, and it's encroaching also a little bit of a congenital narrow canal. Then you can see the adjacent segments at C4-5 and C6-7, and again, that's when Dan Rue, we talked about a plate to this distance, and this is the Hillebrand study, the rate of adjacent secondary degeneration. They didn't really stratify for what were the risk factors. Dan Rue did with his systematic review of the literature where he demonstrated that it was a 5-millimeter plate to this distance, and so that's something that we should all keep in mind in order to mitigate the risk of adjacent secondary degeneration that becomes symptomatic in a shortened time. Obviously, we can get adjacent secondary degeneration over the span of decades. It's an inevitability because of the increased intradiscal pressure, but, and again, Dan Rue and his group wrote extensively about this regarding the need to maintain a 5-millimeter plate to this distance. Regardless, in this case, he's got a cervical spondylosis with radiculopathy, and specifically a right C7 radiculopathy. These would be the ICD-10 codes that would be used. I would use one, not the other, because they are in the exclude one category, so M5323 is probably the best descriptor. What are we going to do? We're going to do an anterior approach to the cervical spine at C5-6 and C6-7. We're going to identify the plate, expose the plate, remove the plate, explore the fusion, make sure we don't have to span that plate across, but we confirmed the fusion before by x-ray or CT, and then we just do a single-level ACDF, prepare everything for arthrodesis, decompress the spinal cord, decompress the nerve roots, place the spacer, and place an anterior cervical plate. How do we do something like that? We explain the plate. Now you see it. Now you don't. Then we do the ACDF. Tough to see on this guy. There you can see the plate shifted over because of the need to find good bone without previous holes, and it was such an overlying plate, I wanted to make sure that we were over some virgin bone for fixation. How do we code this? Anyone who does these procedures recognizes it's a lot of work, and it's a lot more anxiety and exposing this, getting down the plane. Obviously the recurrent laryngeal nerve palsies are of greater frequency in this circumstance. So how do we get to code this? Do we get to code removal of anterior instrumentation? Do we get to code exploration of fusion? The answer is no. No to both. So unfortunately, and remember we saw Easter eggs with the corpectomy case. This is one of the times where we do not get to code more. The additional work of removing the plate and exploration of fusion is simply not captured. This is one of the times where CPT, 97.5% of the time CPT values the work that we do appropriately. Tragically, this is one of the times where it just doesn't. We code as if it's a single level ACDF, and we have to focus on those things where we get a generous reward for the work that we do as opposed to this circumstance where unfortunately the work that we do and the risk involved is simply not captured. So these are the final CPT codes, the 22551, it's a single level ACDF, the anterior instrumentation, the inner body, and the graph codes. So we do all that work, and this is what we get. Now what if we had an adjacent segment generation at two non-adjacent levels? You know, I would have thought, when someone asked this question when I was coding faculty years ago, I thought I was generally mystified by the question, having never seen it. If you're in practice long enough, you're going to see this. And now I can think of example after example, so much so that I'm going to show you one. 56-year-old right-hand dominant woman, progressive gait and balance issues, obviously having myelopathy, can't type, and she does have a C4-5, C5-6 ACDF. It was only 10 years ago, which is early. Myelopathic, positive Hoffman's, Romberg, atrophy of the hand intrinsics. This is her in 2017 when I had seen her, and you can see, again, the plate to this distance, we had discussed that. What did she look like when, okay, so here is the diagnosis, the ICD-10 codes, we're familiar with these, M48 TAC-02 for spinal stenosis, the spondylosis with myelopathy, so M47 TAC-12, and then other degeneration, you can see that at the C3-4 level, M50 TAC-31 is the highest level that she code. Interestingly, this was her imaging in 2009, which I was able to track down, demonstrating already that she has a congenitally narrow canal, probably a setup for this, and anything we could do to mitigate that would be ideal. This was her imaging in 2009, you can see the disc spaces were not very degenerated at that time, plate's a little long, screws are a little long, and so this is 2009 versus 2017, and you can see how Dan Rue would have predicted this with the less than five millimeters of plate to this distance. Regardless, phase one of the operation is going to be taking the plate off, so this is one of the times where I do a two-incision technique, I make an incision above, immediately over C3-4, and then over C6-7, and then I work within that dissection, working above and below to get the plate off, and again, even though all that additional work is done and the risk involved with that, we simply do not have a way to capture that using our current CPT conventions, and we accept that for all of the things that CPT can capture, so we do not waste energy on concerning ourselves with that. Here we are, the incision was incredibly lateral, you can see I marked the incision, you can see the dotted lines, that's right over the sternocleidomastoid, so regardless, I planned my incision more midline, I do a two-incision technique, it allows me at least to work in a relatively virgin plane, and so I did a complete discectomy, after removing the plate, complete discectomy at C3-4, decompress the spinal cord, and then I do the entire operation there, and then I work at C6-7, and get the operation done there, again, these are basically two separate ACDFs done through two separate incisions. So, this is the result in the end, how do I code it? We're going to use the 22551 for the anterior arthrodesis technique, and then the 22552 is if we're doing a continuous adjacent technique, but then the difference will be with the anterior instrumentation, I'm going to use that code twice with the 59 modifier, the 59 modifier now telling my payer, hey, I am actually putting on a separate plate at a different level, non-adjacent, this is not a two-level ACDF, and since I'm putting two separate plates on, I get to capture the two separate work, 59 modifier indicates that I've already coded the 22845 at a full level, and then it's going to be diminished at the second level, 22853, use that for two units at 34 and 67, and then my graph codes. Cervical myelopathy, okay, now this is our, the way to end it, I still remember when this case came in, one of my, I was running late in clinic, one of my primary care providers gave me a call and said, hey, do you mind if I sneak this poor lady in, she's having a hard time using her hand, and then walks in, and I see this. This is not what you want to run into for your last patient when you're trying to get out of there, so this is obviously a very, this is cervical deformity, and cervical myelopathy from a significant spondylotic spine, she has that staircase spondylolisthesis, she's got a severe stenosis from that C5 vertebral body and advanced spondylosis, so 69-year-old left-hand dominant woman with increasing gait imbalance, loss of manual dexterity and profound atrophy of the hands bilaterally, three plus reflexes in the upper extremity, positive Hoffman's and Romberg positive, so everything that we would expect to see, spondylosis present C4-5, C5-6, C6-7, and C7-T1, as we can see there, and so now we say that, you know, you're going to fall in the M47 TAC1, and then I like to report all of these, because at times, even though ICD-10 say report the highest level, if you're getting a prior authorization, and now even with our Medicare patients, we have to seek some form of prior authorization, you have to, I like reporting what it is that I see, so C7-T1 is M47 TAC1-2, but I'm also including C7-T1, and so I like to put M47 TAC1-3, so those would be the codes that I would use in this circumstance, and then the stenosis, you document by site, and again, there's two of them, M48 TAC02 and 03, and there's kyphosis, and we know from Chapter 13, that there's going to be the various circumstances of kyphosis, and the cervical region is going to be 2, so the cervical kyphosis in this case, and again, it's worthwhile getting that ICD-10 book and flipping through it, M40 TAC292, and that's going to be the kyphosis otherwise unspecified in the cervical region, she meets all that criteria, and so this is my ICD-10 coding, the cervical spondylosis with myelopathy, the stenosis, and the kyphosis, so once I have all of those, now I go to the procedure, what did I do, well, I started from the front, I did a C5 corpectomy, put a peak spacer in there, so I know how to code my corpectomy, we went through that, then I'm going to do a C6-7ACDF, and I put a peak spacer there, then I'm going to span the segment from C4 to C7 with an anterior plate, then I'm going to do a posterior instrumentation from C3 to T1, and I'm going to do a cervical laminectomy to decompress the entire spinal cord, and then achieve a posterior lateral fusion, so how am I going to code all that, starting with the 63081, and a C5 corpectomy, that's my C5 corpectomy, the mistake that is on this slide is that the microscope code should be immediately under that, 63081, you see the microscope further down, we do not submit our charges like that, we submit our charges with the microscope code linked immediately to the corpectomy, because it's not like we can use the microscope code for the posterior segmental instrumentation. Then the 22551 for the ACDF, for the 59 modifier, and then we have our arthrodesis at C4-5, this is part of the corpectomy element of it, 22885, these are the arthrodesis of the additional segments, and then we have our 22846, anterior instrumentation code, so we've covered all the arthrodesis, we've covered all of the anterior instrumentation, so we've done everything from the front, and I'm sorry also, the 22854 and the 22853, so those are the inner body spacers that we have been putting in, that's our anterior approach, then from the back we did trough laminectomies, that included more than two vertebral segments, just like we did for that central cord case, 63015, and then the posterior instrumentation, the 22842, again the microscope code has been linked to the corpectomy, and then all of our graph codes, and then the posterior arthrodesis codes, all cover the, all covered for, use the posterior arthrodesis code 22600 for arthrodesis at the C3-4 level, and then four more codes to cover C4-5, C5-6, C6-7, C7-T1, so those are the four additional ones that we use, and with that, we've built this entire complex case, and at the same time, we have finished the advanced cervical coding, part three, these three sessions give you one hour of CME, and hopefully also have facilitated achieving your mastery of coding cervical cases. Thank you for your attention, I hope you find these valuable, give us some feedback, let us know how these are doing, if you want to see more of them, we should have lumbar cervical cases coming on board.

ICD-10 coding

trauma cases

corpectomy

adjacent segment degeneration

CPT codes

cervical cases