This is part two of our introduction to cervical coding. These are going to be specific case illustrations, something that's going to get you through your first year in practice, I would say, with regards to the basics and introduce coding again, whether you're a resident, whether you're a young attending, especially for those of you going into board collection. This is very important. We want to have very good accuracy in our coding. I'm going to share a screen. We're going to get started right away here, getting through the cases. My disclosures haven't changed from the first presentation to this one. Again, this is our first day in clinic. Let's frame this as you've finished residency, you've taken some time off, and now you're starting clinic. I want to get you through clinic. I want you to get the accurate codes for your prior authorization, and I want you to be able to code some cases. Let's do a single-level ACDF, multi-level ACDF, and then we'll do single-level cervical arthroplasty, two-level cervical arthroplasty, and then posterior cervical foraminotomy. Those are going to be our basic cases that we are going to do with ICD-10 and CPT. Again, the basic ICD-10 and CPT review, we are going to be looking at the diagnosis of cervical radiculopathy, cervical myelopathy, stenosis, and cervical spondylosis. Case one. Here we've got an individual, very common, what we see in clinics, cervical spondylosis with radiculopathy. We've got a 45-year-old right-hand dominant flight attendant with a four-month history of left radicular arm pain and axial neck pain after a rough landing. Mechanism of injury was a severe whiplash injury at the time of the landing. Perhaps they were standing up, transitioning, had that bump, and had a herniated disc or cervical radiculopathy in the aftermath. The patient did try to get epidural injection therapy, something always good to document in the history of present illness, because as these cases are being reviewed for medical necessity, they want to see efforts that have been made for non-operative measures and duration of symptoms. Epidural injections is always good to include, physical therapy, even cervical traction, and more than anything, now this patient is on short-term disability, and obviously, in this case, probably a workman's compensation case. The examination is notable for bicep weakness. We're all thinking C6 radiculopathy here, absent bicep reflex, we can almost anticipate what the imaging is going to show. This is a classic, everything is pointing to one nerve root here. Negative Hoffman's, so no evidence of myelopathy, and then no evidence of hyperreflexia. Here we see some cervical spondylosis, positive sagittal-vertical axis, and then the MRI tells us what's going on. There's a disc herniation, and this disc herniation is in contact with the ventral aspect of the spinal cord, and causing some left compression of the C6 nerve root, with a C56 disc extrusion. What I like about the M50 code, so chapter M in our ICD-10 book, gives us great detail, and so that we can go to M50 TAC 122, M50 TAC 122, which will get us to the C56 level. There's several ways to code this, whether if you feel that there's advanced spondylosis, if it's just a generalized radiculopathy, again, the precision of that code, I think, is the most valuable. We always want to use the most accurate of codes, so in this case, where there isn't a significant amount of spondylosis, M50 TAC 122, and this is the procedure that the patient underwent. This is an anterior cervical discectomy with fusion. Here we can see, we see a plate that is separate and distinct, something which is very valuable to put into your operative note. There's a peak implant in there, and obviously, there's going to be some form of autograph that we're using at the time, and mixed with allograft. Here are the codes. 22551 is going to be our arthrodesis anterior approach. The 22845 is going to be our anterior instrumentation. One of the most valuable things to do when you're dictating this note is when you dictate the, you're at the point of the plate, you say, use the combination of words. The plate was separate and distinct from the inner body spacer. The 22853 is the polymer, or carbon fiber, or whatever implant of choice, provided it's not allograft. Allograft has its own code, a structural allograft would be a different code. Then you have the 20936, which is the autograft harvested and mortalized. What does that mean? It means that when I'm drilling the underside of C5 and the superior aspect of C6, I specifically say it, I collected whatever bone and mixed it with mortalized allograft that allows me to use that code, and then 20930 is going to be the mortalized allograft of choice. This is that code, so a single-level ACDF, there you have it, 22551, 22845 is a cervical plate. Again, we always say separate and distinct. With that, you would put a 59 modifier. The 59 modifier on the 22845 is an indication that you did not use a standalone inner body. This is one of what is called the NCCI rules, the National Correct Coding Initiative, that basically is to ensure that we're not using a standalone. When you put the 59 modifier on the 22845, basically that's an external way of communicating the fact that this is a plate that's separate and distinct, and then our mortalized allograft. This is, and then the autograft code is missing there, but what if you say, well, Aetna denied my 22853, and if you're going to use the structural allograft, you're going to use the 20931 with those other codes. Those are going to be for coding a single-level ACDF with either peak or any other biomechanical spacer for that matter versus structural allograft. Those would be the codes. What if I'm doing a standalone? In this setting, there has been issues with individuals saying, hey, look, I am putting in screws at an awkward angle. This is additional time. This is additional risk to the patient. I'd like to be able to use the inter-instrumentation codes. This would not be the appropriate code. When you're using a standalone, the way the codes are specifically written is that the plate has to be separate and distinct. If the screws are going through, whether you're in the lumbar spine or the cervical spine, if the screws are going through the inner body spacer, you will not, it is not appropriate to use the 22845 code, 59 modifier or otherwise. So be careful because that could be problematic over months and years of accumulation of cases. So again, here's our 22551 is for the ACDF itself, the anterior cervical discectomy in preparation for arthrodesis. There should be a 59 modifier. The modifier is a, that this is a mechanism of communicating to the payer that you are confirming that this is a separate and distinct from the inner body spacer, 22853 is a polymer spacer. Then you have the morselized autograft and then the allograft codes. What about case two? Cervical spondylosis with radiculopathy at a 58-year-old right-hand dominant woman with increasing axial neck pain and right radicular arm pain. Normal reflexes, normal gait, Romberg negative. So no evidence of hyperreflexia, no evidence of myelopathy. The bicep reflex is absent and there's a decreased tricep reflex. And then you can see there on the MRI, they do have a positive spurling sign, which is a nerve compression sign, positive shoulder abduction sign. And you can see the imaging here is suggestive of two levels of spondylosis, significant amount of spondylosis, as you can see at C5-6 and at C6-7. So the diagnosis is cervical spondylosis without myelopathy, but with a radiculopathy. She obviously has cervicalgia and she has a cervical radiculopathy. The cervical spondylosis can be best captured with the M47-TAC2 code. There is no myelopathy, it's just radiculopathy. And so I would use the M47-TAC2-2 for this diagnosis. We can also add a radiculopathy and a cervicalgia, but there's an exclude one code. So the codes in this setting, when you have the exclude one code, you do not use your M54 code because that's going to be inherent to it. They both say radiculopathy. Since there is an exclude one on that, we would not use that code. So you'd be using M47-TAC2-2 for the C5-6, C6-7 cervical spondylosis with radiculopathy, and you can use cervicalgia. So how are we coding a two-level ACDF? And again, this is a two-level with two levels of peak in this setting. And so there's a separate code that we add to that, the 22551. The 22552 is the additional segment. So the 22551 covers the C5-6, 22552 covers C6-7. Then you have the 22845. Again, we would be using a 59 modifier when we submit those codes. And that's the plate I always put in the comments, separate and distinct from the inner body spacer. And then I would use, in this setting, there's a couple of ways to do it. I would be using two units, 22853 times 2 would be the better way to do that. Then you have the 20936 and the 20930, just like we did before. And so there's nothing earth-shattering about this one. The cervical radiculopathy, case three, 38-year-old right-hand dominant firefighter with incapacitating right radicular arm pain after a wall collapse atop his head. He's got right arm pain. He comes in, actually, with his right arm abducted, holding the left side of his head. So his right arm doing this, giving us a shoulder abduction sign, decreased grip strength. He's in pain. And he has a friend in whom he did an artificial disc in. And he's very clear that he doesn't want a fusion because one of his other friends has a fusion, had problems with it. He wants the artificial disc. And he's got this. So here we have a C7T1 disc extrusion. And so diagnosis here is going to be a cervical radiculopathy at C7T1. So that's M54 TAC 13. And so we can also use, again, the precision of the M50 code. And that would be M50 TAC 13. These, again, they exclude one another. So I like the more accurate of the two codes. So I like the M50. But either one of these would be correct. M54 TAC 13 or the M50 13. And in this case, he didn't get an artificial disc or a fusion. He had a minimally invasive microdiscectomy. And again, for this, we are taking out soft disc. So we are going to be doing a laminotomy to access the neuroforamen, removal of or elevation of the nerve root and removal of the disc extrusion. And we're going to use the microscope code for that. Even if we use, so this is a point that is worthwhile making because you're seeing the microscope code appear for the first time. Even if you use the microscope, and I do for all my ACDFs, you can use that in the ACDF code or when you code the ACDF because it has been included with the valuation of that code. So there's a de facto bundle that has happened. So you cannot build the microscope code separately. You're going to see in the more advanced cases that there is a, you're going to see that there is a case where you can use the microscope with the corpectomy. So that's our summary. M50-TAC1-3, C8 radiculopathy, and then those are the codes that we use to do the procedure. Case four, cervical radiculopathy managed with cervical arthroplasty, 42-year-old nurse with incapacitating left radicular arm pain after helping lift a 350-pound patient. Month prior, did get an epidural injection, but that made matters worse and cannot tolerate physical therapy. Again, all of these elements are very important, I think, to document in the HPI to lay the argument, make the case for surgery that you've tried all forms of non-operative measures. And then once again, she's got the shoulder abduction sign. Absinthe C7 reflex, positive shoulder abduction sign, positive spurling sign, and weakness in that. And here you see her with, again, positive SVA. She's probably leaning forward. This is her MRI. And so what we're going to do here, there's a deflection extension. So in this case, not a lot of spondylosis. This is her. She does have a positive SVA, which is not perfect for arthroplasty, but this is likely because of the compression of the nerve root. So this is a patient who has a lept C7 radiculopathy from a C6-7 disc extrusion, no significant spondylosis. This, to me, in my hands is an artificial disc. Because there's no spondylosis or significant spondylosis, I like the M50 code, not the M47-22, but rather the M50 code. So I would use M50-123 because it's a C6-7. And this is the patient with the artificial disc that has been put in, and she has resolution of her symptoms. And how do you code this? You use 22856. That's the only code that you would use. You say, what about the rest of the code? This captures all of the work. It was once when it was evaluated, it was evaluated in a very tight, all-in-one type manner. There's no arthrodesis code, obviously. There's no bone graft codes because it's motion preservation. So there you have it, 22856. So you can see the difference in the number of codes, one versus the other. Case five, cervical radiculopathy managed with arthroplasty. This is going to be a, this guy was working oil rig, yeah, 40-year-old right-hand dominant man injured on an oil rig in Alaska. New radicular arm pain, right arm weakness to the point that he's unable to perform his job on the oil rig. It is a workman's compensation case. He's got a cervical collar, bicep weakness, tricep weakness. So he's looking like a 5667. He does have some mild hyperreflexia, full range of motion. And there you see the disc protrusion. Again, not a lot of spondylosis. This is a big, big guy. And you can see the absence of any disc osteophyte complexes, but the disc herniations are causing him some significant discomfort, right? C6 radiculopathy with a disc extrusion at 5'6", right? C7 radiculopathy, C6-7 disc extrusion without spondylosis. So in this case, I would say that, and they tell you to use the highest code. I submit both codes, M50-TAC-122, M50-TAC-123, because I'm going to be putting a request in for a two-level ACDF. And so even though the ICD-10 tells you to code at the highest level, which would be just the M50-TAC-122, I feel that the goal of using these diagnosis codes is to get as accurate and close as possible to the clinical image. I should be able to look at these codes and imagine in my mind what it looks like. So I would use that. And coding these, again, very straightforward, 22856, and then the additional segment of the 22858. So there you have it. Now you've done a two-level. You can't really see on the lateral as well, but you can see that on the AP. And this is just pointing out some heterotopic bone formation that can happen, and that always concerns me on whether or not they'll be able to preserve motion over time. But you can see also an improvement in the sagittal vertical axis from just decompressing the nerve roots. So again, I add this because it doesn't need to all be coding, but you can see improvements in the plumb line from doing decompression of the neural elements. Finally, a case of cervical arthroplasty gone awry, 32-year-old, active duty Navy SEAL, eight months out from a C5-6 arthroplasty, returned unrestricted full duty at a month. We first started doing this, we didn't have any really guidelines on what limitations to put on these very active individuals. So we just let them go back after a month. But he did return with increased neck pain. His neurological examination was completely unremarkable. And what do we see? We see osteolysis. This has been reported. The osteolysis has been reported in the past. I was very concerned that we'd have to do a full cortectomy to take care of this. You can see that blooming osteolysis. This is one of the KEAL devices. So anytime I have anything, whether it's a hardware failure or in this case, artificial disk issue, I think that there's an ICD-10 code that covers that nicely. Captured here. And it's other mechanical complication of a orthopedic device. And then in this case, it was converted to an ACDF. How would you code something like this? This is now getting a little complex. So the 22864 is removal of a total disc arthroplasty. There's a code specific to that. And then the 22554, arthrodesis anterior inner body, again, this is the previous codes that we used to use for arthrodesis before it became the 22551. But in this case, all we're doing is just the arthrodesis now. And then we're going to use a plate that's separate and distinct. And we use some structural allograft. So in this case, there's no 59 modifier because there's no 22853. So that sums it up. That's the coding part two. And then stay tuned for part three.

cervical coding

accuracy in coding

ICD-10 coding

CPT coding

cervical surgeries