My name is Lou Tumialan, John Ratliff and I are the co-directors of this course. What are those CPT codes that 63030, what does that mean that 63047, what are those codes? What is the anatomy that they have to do with? So what exactly is a CPT code? Well happy 51st birthday to CPT, it was established in 1966 because there were so many different ways to actually report what was being done and as always we want to codify things and you want to have a uniform way of getting everyone on the same sheet of music. These are healthcare professionals, healthcare entities such as hospitals, clinics, home health agencies, they all needed to have some element of a uniform platform from which to be able to describe a procedure, not a diagnosis. The CPT code is now the preferred system of all healthcare providers. There are other systems that are used but the AMA owns the CPT system and this is the uniform platform that the vast majority of us are using. The codes don't necessarily change but new codes are being brought in or codes have to be modified. In 1976 when CPT was just 10 years old, we didn't have minimally invasive. We always want to make sure that we are using the most current recommendations for coding using our modifiers correctly. The modifiers are becoming its own entity altogether. There are 9,600 CPT codes, probably about 100 to 150 that we use quite frequently and of that, the 150 codes, I would say that if you distill those down to about 30, you're probably hitting about 75% of your practice. CPT covers about 98% of the procedures that we do perfectly. There are unlisted codes. The purpose of an unlisting code is so that we can capture at least some of the work that is being done. In addition to unlisted codes, there are tracking codes. Why are there tracking codes? In order to figure out if in fact these codes are being used with a frequency and they can be understood by CMS to see if they are actually worthy of getting their own code. We'll go first with cranial anatomy and terminology. The realm of neurosciences will include the central nervous system and the peripheral nervous system. We have the brain and we have what protects the brain and then we have the various elements that we'll go over and then the spine. The brain will give way to the medulla, the brain stem and the spinal cord and then the various vertebral bodies that protect it. The peripheral nervous system obviously for the peripheral nerve surgeons who will be taking care of diseases of entrapment. The brain is protected by the cranium and the cranium is going to be separated into a frontal bone, temporal bone, parietal bone, occipital bone. These are the bones that correlate with the various lobes of the brain. For example, in a skull base lesion, we're going to go through the temporal bone to get to the temporal lobe to be able to do this lesion. The ENT doctor is going to help us with the approach, which is why there's an approach code and then the definitive procedure, which is maybe done partially by the neurosurgeon or done wholly by the neurosurgeon. The cutoff as oftentimes are lines that are drawn in the sand in CPT and that is whether or not it's 5 centimeters, less than 5 centimeters, greater than 5 centimeters, all have relevant importance. This is a cranioplasty, for instance, interoperative footage of a reconstruction of the cranial vault that may have been destroyed either by tumor, by trauma, by infection. We as neurosurgeons, in order to get to certain lesions of the brain, find ourselves traversing sinuses. For example, a transpinoidal approach to resect a pituitary adenoma. And so the reasons for, again, understanding a little bit about how to traverse certain why that code exists the way it does, because there are different ways to do a hypophysectomy or resection of a pituitary tumor. And that can be done either through a transpinoidal, transnatal, transeptal approach, or we can do a craniotomy and get to it, or we can do a neuroendoscopic approach. One of the other things that we'll see is whether a meningioma is going to be supertentorial versus infratentorial. A posterior fossa or infratentorial lesion involves a significant amount of work in positioning. And it also is a much less forgiving corridor to traverse and resect. And so it has a much higher RVU than a supertentorial lesion. And where does that tentorium take place? As you can see here in the red. And so this is the cutoff line for those lesions that are going to be infratentorial. So you read a cerebellar lesion, you know by default because it's in the cerebellum and below this red line, that by definition is an infratentorial lesion versus anything in the frontal, temporal, parietal, occipital lobe would be a supratentorial lesion. And here you can see an illustration of the dural membrane, which is known as the tentorium. And infratentorial is the demarcation from the dura that will put us into the posterior fossa. We see the craniotomies used for supratentorial except for meningioma. Meningioma has got their own codes. The skull base is going to be very important to understand, skull base approaches. So as we do approaches into the middle cranial fossa, there will be various approach codes that are used. And so this gives us a bearing of where we're working. So we have anterior, middle, and posterior cranial fossa. And then the bones of the skull base are the ethmoid, sphenoid, occipital, frontal, and parietal. And so this is an example of a skull base approach. A 61581 is a craniofacial approach to the anterior cranial fossa. It's extradural, including lateral rhinotomy, orbital exoneration, ethmoidectomy. Again there you see ethmoid is the bones of the skull base. The sphenoidectomy, again that's the sphenoid, another bone that makes up the skull base. A 61592 is the temporal bone, postauricular, behind the ear to the middle cranial fossa. Again these are various approach codes and that's the anatomy that goes along with it. There are approach codes and definitive codes. All of the approach codes are going to be paired with a definitive code. The most important thing for this lecture is to understand the anterior, middle, and cranial fossa so that you can put a name with a face. Once we are inside the cranium, we are dealing with the meninges. The meninges are the layers that protect the brain, the dura mater, which is the tough mother. The arachnoid is the thin, delicate membrane, which the early anatomists identified that it had a very spider web appearance, therefore giving it the arachnoid type name. And you'll hear terms like arachnoiditis, arachnoid cyst. Those are the elements that are beneath the dura and the pia mater is completely adherent to the brain. Trauma. This is an epidural hematoma, which can be very characteristically identified by this very lenticular shape, which is very different than a subdural in how it's very focused because this represents where the dura is attached to the skull. Typically, it's the middle meningeal artery, which happens from a fracture in the temporal bone that begins to bleed. This is a subdural hematoma, and what's different here, when you look at this very focal area, what you see is a more what we call holohemispheric. This is another trauma patient, typically happens from high-energy motor vehicle accidents in my experience. Here are the codes that we use for evacuation of the hematoma, craniectomy or craniotomy for evacuation of supertentorial, there again, supertentorial, above the tentorium. So extradural or subdural, so there's not a delineation of whether or not it's above the dura or below the dura. And then evacuation, so that the codes will go up as we go deeper into the brain because what does it mean to be taking something out that's intercerebral? That means that the bleeding is not outside the brain or outside the dura, but inside the brain itself. That is a higher level because that involves a higher degree of involvement as far as the risk and the technical elements of the surgery itself. And then a separate code altogether to take out a subdural hematoma, which is extradural but infratentorial. Why? Well, because you have to position the patient differently and the risk is greater and difficult corridor to navigate, therefore with a different relative value unit. The brain, now we're going to go down to a closer view of things. The cerebrum, we'll go through the various lobes of the brain, the cerebellum, frontal, parietal, temporal, occipital. Brainstem is going to be the medulla, pons, the midbrain, and the diencephalon. So at times you may be reading one of your operative notes from one of your surgeons. You may hear the term sagittal, coronal, and axial. When you read these elements on an operative note or perhaps a clinic note, this is exactly what they're talking about, coronal plane of the pathology, sagittal plane of the pathology, or axial plane. Here are some images of the brain. This is an anatomic pathological specimen. Again, the cerebrum, and there you see the underside of the brain and that prominence here at the base of the brain, therefore given the name the basilar artery. Dividing up the lobes of the brain, the frontal lobe, the parietal lobe, the occipital lobe, and the temporal lobe. This is what we'd call the sagittal view, looking down through a hemisection of the brain. And again, the various lobes of the brain where we have a lesion that your surgeon is taking out a frontal meningioma. That's very different than taking out a meningioma from the cerebellum, which would be infratentorial. And then lesions from the parietal lobe, which at times, in a dominant lobe, you may find yourself reading that there's intraoperative mapping, occipital lobe. And so these are going to be examples of either brain tumor, this could just as likely be an infection, but this is a lesion in the temporal lobe. This is a hemorrhage in the posterior fossa, which would be infratentorial. The ventricular system is especially important because this is where we place our external ventricular drains, which would be placed either for intracranial pressure monitoring. What we're trying to accomplish in shunting is diversion of the cerebrospinal fluid, whether it's being done for trauma, intracranial pressure monitoring, or for hydrocephalus, secondary to a tumor, or after having had an aneurysm. So one of the things that can happen in someone who's had a ruptured aneurysm is that the cerebrospinal fluid builds up. There are parts of the brain called the choroid plexus. The choroid plexus generates the cerebrospinal fluid. That cerebrospinal fluid is part of the circulation, circulates when we do a lumbar puncture or sampling fluid that was made in the brain. The part of that guttering system means that the fluid that builds up in the brain needs to drain into the lumbar cistern. So this is what the ventricular system looks like, and the emphasis here is the third ventricle because something that can be done for hydrocephalus can be done endoscopically, and it's called an ETV, an endoscopic third ventriculostomy. A small opening into the floor of the ventricle that allows for communication and thereby treatment of hydrocephalus. The cerebrospinal fluid circulation, we discussed this, is the production of the cerebrospinal fluid that circulates through the entire central nervous system. It's the same cerebrospinal fluid that we have in our lumbar cistern that is tapped when we do lumbar punctures. Cerebrospinal fluid flows through the various openings, foramen of Luschka, foramen of Monroe. It can also enter through the sagittal sinus, through something called arachnoid granulation. This is an example of hydrocephalus. This is an individual who can no longer drain the cerebrospinal fluid, and here you have a normal ventricular system. These are the anterior horns. This is called the trigone of the ventricles, and this is part of the normal functioning cerebrospinal fluid circulation. This is what happens when it doesn't, for whatever reason, whether it's been a tumor, whether it's been a trauma, whether it's been a ruptured aneurysm, a ruptured AVM. And then we place a catheter, connect it to a valve, and then connect that to tubing that can go into the peritoneum, into the lung, to the heart, in order for that cerebrospinal fluid to be diverted, drained. And this is the various codes that can be used, again, whether it's placed in the lung, and this is management of the proximal and distal. That's going to be always what was done at the time of the revision. And so it's helpful to understand that the catheter was placed here, connected to a valve here, and then passed into here, because there's going to be distal revision codes, there's going to be proximal revision codes, and understanding that can be helpful. This is a cerebrospinal fluid leak that may have been either spontaneous, secondary to trauma, secondary to surgery. And this is an example of having to find that, because there are codes that include repair of a cerebrospinal fluid leak, and typically these could be spontaneous, could be from trauma associated with tumors that are on the skull base that leave these large defects that need to be repaired. The cerebral circulation is pretty straightforward. There are four hoses that go to the brain. We have the hoses that we can feel in the front, and that's our carotid, and then we have the hoses that flow in the back, and we can't feel those because they're inside the vertebral bodies. They have little areas called foramen transversarium, little rings that they flow through, so we can't feel them. And those are called the vertebral arteries. So you have two carotid arteries in the front, two vertebral arteries in the back. The carotid artery will enter the cranium and then will branch off into the anterior cerebral artery and the middle cerebral artery, whereas the vertebral arteries in the back, instead of branching off, they join and they form a basilar artery, and that basilar artery will then branch off and form various arteries that will feed the posterior circulation, the superior cerebellar artery, the posterior cerebral artery, the posterior inferior cerebellar artery. So those are the branches of the posterior circulation, and then they will all form together something called a circle of Willis, named after the anatomists who identified that the design is very clever in the sense that you have redundancy, lateral flow provided it was done incrementally. Aneurysms tend to be at branch points, where blood is flowing and hitting the wall and then having to branch. If you see a basilar terminus aneurysm, that's typically right where that basilar artery will branch off. And so instead of having to go in and operate on this, technology has reached a point where we can go in through the femoral artery and catheterize the cerebral circulation, which has its own set of codes, depending on how far in the vascular tree you go. And then, instead of just getting an image, we can now place coils. And we have clipped ligations on aneurysms, involves craniotomy, mobilization of the lobes of the brain to be able to reach the circle of Willis and identify the aneurysm, obtain proximal control, meaning that remove the aneurysm from the circulation by putting a clip across the neck of it. There's new codes for endovascular neurosurgeons. These are going to be the various codes that are used. Now they begin to make sense, because we know that we all start in the carotid selective catheterization of arterial system, whether they have to start in the femoral artery and then work their way up through the brachiocephalic branch, and then they'll go further and further along. We'll go through some spinal terminology. 34 vertebrae, 7 vertebrae, 12 thoracic, 5 lumbar, 5 sacral, 5 coccygeal, but they're really a fused segment, so is the sacrum. But we separate that, the sacrum, S1 and S2, and instrumenting S1 and S2. The cervical spine, we can begin to break that down. The axis and the atlas, the atlas holds the weight of our heads upon our necks. The axis makes sense, because that's how we swivel. Below the axis is then what we call, beginning at C3, is the subaxial spine, which is where probably the majority of our cervical surgery takes place, anterior and posterior, where we do anterior discectomies, corpectomies, at times take out tumors. There's nothing else that looks like the C1 vertebrae, and there's nothing else that looks like the C2 vertebrae. There's striking similarities between C3 down to C7, where you have the vertebral body itself, which is important to understand. There's corpectomies that we are coding. There's the disc space itself. We're doing a discectomy, and the difference between that, the fact that there is an uncovered tibial joint, or the uncinnate processes, or the joints of luschka, and that is going to be what you'll read when someone is saying, I'm drilling out the uncovered tibial joints in order to decompress the nerve root and perform a generous foraminotomy. The lateral masses are a target. When you rotate the spine 180 degrees, and we're looking at it from the back, you can see that these articular pillars, which are perfect targets for placement of lateral mass group for segmental or non-segmental instrumentation. The thoracic spine, again, in those people coding for surgeons that do scoliosis, the kyphotic curve is part of the balance of the spine. We're supposed to have a kyphosis, because we have lordosis in our cervical spine. Sometimes you'll read in either the radiology report, or perhaps the surgeon's report, loss of the normal cervical lordosis. But that normal cervical lordosis, as we see here, is supposed to be balanced with a kyphosis, because in the lumbar sacral spine, you'll have lordosis again, and that gives us our S-curve, and it's the loss of that S-curve that gives us our appearance as we get older, and it's where we lose height. Parts of the thoracic vertebrae are going to be parts of the lumbar vertebrae, because they're all very similar, although they have a very different configuration. The only difference is that the thoracic spine has a place to put the rib onto. You still have a vertebral body. You have a pedicle. The pedicle is obviously what we turn to when we need to stabilize. We remove generous parts of the bone in the thoracic spine when we take out tumors, especially metastatic lesions or interdural lesions. We can do costotransversectomies. We can do transperdicular decompressions. You can also see these are the facet joints. They're the brake pads. They're the parts of the vertebral body, posterior elements that prevent anterior translation of one vertebral body over another. And you can see the configuration here is very different than what you'll see. The coronal configuration of that is very different than what is seen in the lumbar spine. Lumbar spine, five lumbar vertebrae, again, you have a lordotic curve, and that's part of the balance. You undoubtedly read some reports, loss of sagittal balance, flat back as an indication for surgery, in which case when you have a flat back, your surgeon's probably doing a lot of osteotomies, and those osteotomies are being done in order to be able to restore the lordosis in the lumbar spine. Very similar to the thoracic spine, the vertebral bodies. They have a body, pedicles, facets. Again, you can see the different configuration for the facet joints, which allows us to use facet-type screws. Transverse process, which is where we lay down our posterior lateral fusion. We decorticate the transverse process. The spinous process, which has become, again, another interesting target for us as we begin to put interlaminar devices using the spinous process to distract and create more room. The sacrum 5, fused vertebrae, the most relevant to these areas is S1 and S2, which are targets for us to place screws. The coccyx is our tailbone, everyone. Coccygectomy is a procedure not only do I hope I never see, but I hope I never do. And there it is. This is the code that I will never use for my entire career, barring some seismic change in spine surgery. What are the approaches to the spine? We can get to the spine in all sorts of different trajectories. Those of us who code for spine surgeons are familiar with the anterior approach. We approach the anterior cervical spine routinely. It is perhaps the first minimally invasive procedure we ever did, dating back all the way to 1955 when it was introduced. We also approach the lumbar spine anteriorly. We do anterior lumbar interbody fusions. And for the purposes of CPT description, a trans-psoas approach is still an anterior approach, because it's certainly not posterior. And now there's pre-psoas approaches also, which are anterior. The lumbar spine is also approached routinely posteriorly. That's how we approach a lot of procedures for scoliosis, for regular degenerative disc disease, spondylolisthesis, a common diagnosis that we see amongst our patients. We do lateral approaches, which again are considered anterior approaches for the purposes of CPT. But we should know that there's a true anterior lumbar interbody fusion approach, anterior approach. And then there's the lateral trans-psoas approach, where we're actually going beneath the rib cage, sometimes in between ribs, to approach the disc space. In some cases, individuals have had surgery, for example, from L3 to S1, and it would be a very challenging procedure for that individual to undergo a procedure at one level above, having to expose the previous instrumentation. Whereas a clever solution to that is to approach from the side. And then there's always the combined approach. Those individuals who have a steep sacral slope, where the L5 vertebral body is slipping off the sacrum, you can approach that advantageously from the front, where that level is looking at you in the face, versus approaching from the back, where it would be very difficult to reach. And place the L5 vertebral body back on S1 with an anterior approach. But because of the unique biomechanical forces at the lumbosacral junction, you would then go from the back and place pedicle screws into L5 and S1. That's the rationale behind that. This is an image of the anterior cervical spine, anterior approach. Again, there's a natural cleavage plane. There's minimal disruption. These become outpatient procedures. Patients seldom describe any significant discomfort. And this is the anterior approach, anterior exposures, where it allows us to expose just the disk space, or the entire vertebral body, for one, two, or three levels, sweeping the carotid and the jugular venous complex laterally, and the esophagus and the trachea. Immediately, there's an avascular plane that allows us to safely reach the anterior cervical spine. We'll go over all of the graft-type material that can be placed in here, but this is an example. These are called caspar posts, named after Dr. Caspar, where the disk space is distracted. It allows us to restore, or we use that term lordosis, people who lose the disk height and have osteophytic ridging in the back, go into kyphosis. The distraction of that disk space is accomplished through caspar posts, this is an illustration of that, and then placement of graft. We don't use the 63075 very often, we still use it, but we don't use it for routine anterior cervical discectomies. Fusion has its own code now, but these are the arthrodesis codes. That's the work that's being accomplished, preparation of the end plates. At times we have to drill, at times there's no disk space. These are examples of cervical spondylosis. This is one of the ICD-10 codes that is frequently used is M47-22, which is cervical spondylosis with a radiculopathy. And then this would be an example of coding. This is a case where obviously a two-level anterior cervical discectomy was performed. They obviously did not use cortical cancellus. These are tantalum markers that are used because the polymer itself is invisible to x-ray. It's not invisible to the surgeon, but it's invisible on x-ray. So they put these tantalum markers in so that we can see where the inner body devices in space typically fill either with local autograft or morselized allograft. It's got a chamber and that is the chamber is filled and packed and then the graft and then secured with an anterior cervical plate. And so in this case we see a 22551, which is the anterior cervical discectomy that was done at C56, the 22552, which is the additional segment, and then the anterior cervical plate that is placed, the anterior instrumentation code, and then the 22853, which is used twice. And then we have the morselized allograft code. Again, the goal here is to understand the anatomy. This patient shows up with neck pain, arm pain, and sheer misery. And then we look at this MRI. We confirm that in fact they have nerve root compression syndromes. We take them to this thoracic spine. Again, this is going to be more anterior approach. This is going to be a transthoracic approach where in the lower areas we have to take apart the diaphragm and then reassemble the diaphragm. This is when we use our 62 modifiers of having a cosurgeon involved. These are thoracolumbar approaches where we have to take down the diaphragm. Typically it's a vascular surgeon or a trauma surgeon doing the exposure, taking down a rib, and then we can harvest that rib and use that rib for graft material. At times we have to do this for tumor, in which case we don't expect to get an orthodesis, which is one of the few times that we use the 22859 as opposed to the 5.4, because what we're trying to do is get the tumor out, stabilize. We don't anticipate an orthodesis. Sometimes what we're trying to do is preserve the dignity of the patient to have bowel and bladder function and ambulatory status, but we don't anticipate a fusion to happen because the life expectancy unfortunately in some of these cases with widely metastatic disease is just months. This is an illustration of a laminectomy, the lamina being removed. For example, T4 and T3 are no man's land as far as getting to it anteriorly. Why? The big thing beating in front of our chest that's connected to that big red hose, very difficult to move those structures. And so instead of approaching them anteriorly, we can still get to the anterior spine through a posterior approach. We do that through transpedicular approaches or even what is called a transacostal vertebral approach or a costotransversectomy. So we are able to get all the way to the front of the vertebral body and we can remove entire tumors and decompress the spinal cord by these approaches and still accomplish corpectomies without going anterior. So this is 360 surgery approaching the anterior spine through a posterior approach, which again, the reason why these codes change in nature is because the degree of difficulty goes up significantly, especially when you're doing a costotransversectomy at the T3 to decompress a lesion causing compression of the spinal cord. So we talked about an anterior approach. Typically an anterior approach is very favorable at L5-S1 or combinations thereof. Typically as we go higher, the anterior approach after L4, you can still reach L3-L4. L4-L5 can be reached, but then we start looking at these as being more transverse approaches. Obviously accessing the anatomy posteriorly tends to be more straightforward. We try not to use in our dictations as best as possible trade names like the ones that are listed up there. If we're going to reach the lumbar spine through the psoas, then we'll say trans-psoas approach to the L2-L3 segment. Preparation of the implants on the underside of L2, superior aspect of L3. Placement of a titanium-coated peak graft with morselized bone graft for an L2-L3 arthrodesis. So we don't need to use trade names, so that's how we approach it. Anytime we're looking at coating for the cervical thoracic lumbar spine, any spinal procedure that we do, we can always break it down into these four categories. Once we do that, then we just need to figure out where in the region of the spine we are. That's the basic 1-2-3 of coating. We always put our decompression codes. Sometimes we stop there. Sometimes you have someone with neurogenic claudication lumbar stenosis, and then we do a lumbar laminectomy. We're done. So we do a 6-3-0-4-7, and that's it. Well, we can add a microscope code, 6-9-9-9-0. But at times, not only do they have stenosis, but they have instability. They have anterior translation of one vertebral body over another, spondylolisthesis, Greek for spine and slip, spondylospine, listhesis, slip. If you have slip of the spine, and that's a component, then decompressing them may not be enough, especially if they have instability, in which case you have to not only decompress them, but you have to offer them stability. You offer them stability through two ways. The first is by getting them the instrumentation, which is going to be your non-segmental instrumentation. Say, for example, one of the most common things that probably we deal with as neurosurgeons is a mobile grade 1 L4-5 spondylolisthesis. That means that the L4 and L5 vertebral body are not lined up. Typically, the L4 vertebral body has slipped over on the L5 vertebral body, pushing it into a nerve root. So what are we going to do? Well, the first thing we're going to do is we're going to decompress the fecal sac, decompress the bag of nerves that go to the legs, which is why they're here to see us to begin with. Then, we have to do our best to get those two vertebral bodies aligned. We're going to get that done one of two ways. After the decompression, so we've used our decompression code. We do our non-segmental instrumentation, placing pedicle screws into L4 and L5. Whether they're done open or minimally invasive as a material, it's the same code. Then, we will do the orthodesis code, which is typically the 22633, which is going to be a combination of the posterior-lateral fusion along with an inner body fusion. Any graft that, whether we use local autograft, if we harvested bone from within the same incision, typically the lamina, then we mill it up. So that would be one example. We can do that in the cervical spine, the lumbar spine. These are all the system. Our 6300 codes, our orthodesis codes, our 2200 codes, the instrumentation codes are going to be the 228 moving forward and the bone graft codes. We hit all of those when we have done a complex procedure where we've done a decompression, orthodesis, instrumentation, and used bone graft. These are the various types of bone graft that are available, whether it's allograft, structural or morselized, whether it's autograft harvested from within the same incision, and then a structural autograft, which is harvesting from a separate site where we have to structure and shape a graft to fit a specific area. At one point, how all anterior cervical discectomies with fusions were performed decades ago and now has gradually fallen out of favor for the simple reason is that harvesting tricortical graft from someone's hip results in pain. For that reason, especially with the availability of all these other grafts, why we've gone, especially with the cadaveric grafts that are available and the biomechanical grafts, now metal is making a resurgence back into the spine. These grafts can be shaped exactly to the size that we need to fill the space based on trials and at times can be far superior than what we can shape ourselves. Let's say this slide is dated, and it is. It's got a date on it. 2016 and before. So, this is no longer what we use. Again, PEAK is ideal biomechanical spacer. Metal sometimes we feel is too hard and cortical cancellous grafts can be too soft and be resorbed. Polyether ether ketone can't develop an immune response to it because the molecule is so big. Develop antibodies to that. But it also is a very good biomechanical implant for the simple reason that it has a modulus of elasticity in between cortical cancellous bone. So, it's not too hard and it's not too soft. But there's problems with this too now because apparently it forms a biofilm layer and the bone doesn't like growing onto it. And so, now manufacturers are beginning to coat this with metal because bone loves metal. And now they're saying, well, why don't we just make the whole thing out of metal? And then we look at the x-rays. I can't tell if there's bone growing through there. So, let's make it half out of metal and half out of PEAK or combinations thereof. Regardless of what we're using in there, we're not going to use a 22851. 22851 came up on a screen. Not that it was being over-utilized. It's just that the number of cases were going up and people weren't harvesting autograft anymore. And so, as a result, the 22851, when anything hits the screen on CMS, they review the code. They go, why should we be using this? Because the initial spirit of the 22851 was to fill up the biomechanical spacer. And typically, that involved a lot of work, meaning that I had to carve out all of the bone from this tumor, put in Steinman pins, pour in cement, keep it away from the spinal cord, let everything dry. Now, I've created this space that had a certain value to it. Well, tapping in something that was pulled off of a shelf, opened up, filled, didn't capture that. And so, as a result, it was revalued and divided into three different codes to include those inner body spacers that contain their own anterior instrumentation. And so, the 22853 is really our new 22851 because 22851, I was using for this purpose anyway. The 22854 is going to be when we're filling a corpectomy spot and still wanting to accomplish an orthodesis. And the 22859 is when we're just trying to fill the void that was created, but it's not necessarily an orthodesis. And these are the code descriptors that are used. So, now we have the 22853 biomechanical device with an integrated anterior fixation at one intervertebral body disc space for orthodesis. So, the intention is orthodesis. So, whether we're using the 22853 here, you can see that there are biomechanical spacers in a likely 4-5 spondylolisthesis. This would be the same code here. There is no anterior instrumentation. This is not the way CPT defines it. This is already now incorporated into the code itself. The actual code reads, insertion of inner body biomechanical device synthetic cage mesh with integral anterior instrumentation for device anchoring, screws, flanges. When performed to intervertebral disc space in conjunction with intervertebral orthodesis. There's no anterior instrumentation regardless of the fact that there are screws there. So, you don't use your anterior instrumentation codes for this. The 22854, we're trying to achieve an orthodesis. So, in here there's a plate covering it, but you can see the spacer. This was for a corpectomy done for a trauma where someone had an L2 burst fracture that was taken out through a thoracolumbar approach and removed. In this case, this was a burst fracture at C4 where an entire corpectomy was done and a corpectomy by definition is greater than 50% of the vertebral body removed and filled with a spacer. The intention here is not just to hold the space. The intention here is for orthodesis. This is the 22859. These are examples. This is a defect being filled with methamethacrylate and you can see that this is a chest tube that has been cut and then they're infusing that chest tube with cement. They're spacing it, they're cutting it, they're sizing it. It's got to be just right. They fill it and then they put a metal on it. Again, the spinal cord is right here. You do not want that cement going everywhere. You need it to be contained because if it spreads, then you have a problem and that will not fuse. We have not put the elements of fusion into play here. That's not the goal of this, but the precision and the craftsmanship is different. Ergo, the 22859 having a different value. Laminectomy code 6300. This is going to be removing different parts of the lamina, 63047, or whether or not we're just taking a microdisc or just doing a disc herniation, 63030. 63020 is we're doing a posterior cervical foraminotomy to decompress one nerve root, which is different from doing a posterior cervical laminectomy, which is decompressing the spinal cord and the nerve root. Or we're just decompressing the spinal cord without decompressing the nerve roots. For example, trough laminectomies without facetectomies or decompressing nerve roots, we just use 63015. Again, this is resections of parts of the lamina. The 63047 is going to include a foraminotomy. We talked about corpectomies and in the cervical spine, at least 50% has to be removed. When you just remove the inferior part of the vertebral body in order to accomplish a decompression of the disc space, like I said, sometimes we have to drill quite a bit of the vertebral body just to reach the posterior osteophyte and decompress the spinal cord. However, if just drilling a couple millimeters above the disc space and a couple millimeters below the disc space, that is not a corpectomy. For a corpectomy, you have to remove 50% of the vertebral body and that's a corpectomy. This is a corpectomy. I think we can agree that in order to be able to put this spacer from here to here, you can see the tantalum markers here and here, and you can see there's just nothing in between there. This is a corpectomy that was done, the end plate prepared for fusion, but greater than 50% was removed there. The spinal cord ends at L2, the spinal canal itself ends at S2, and the cervical nerve root, so at C4-5, the C5 nerve root is exiting beneath the pedicle of L4 in the lumbar spine. The like-numbered nerve root exits under the like-numbered pedicle. So, beneath the pedicle of L5 is exiting the nerve root of L5. The same codes again, the 63045, 46474848 is the additional segments. Single inner space, very important to mention that the decompression is being accomplished of a nerve root with a peraminotomy, medial fasciatectomy in addition to the laminectomy. Tumors, we are looking at the spinal cord. Intradural lesions can be divided into two groups. Intramedullary mean that they're inside the spinal cord. The stakes are very high when you have lesions there. If they're extramedullary, stakes are still pretty high, but not as high. And then if they're outside the dura, for example, metastatic lesions, laminectomy for resection of an extradural lesion means it's outside the dura. It's probably a tumor growing from a vertebral body or a spinous process or some sort of metastatic lesion. When you have a meningioma, and there are examples here, this is going to be extradural metastasis. So, this is a tumor. You can see there's tumor on both sides, but the tumor is growing outside the end, pushing on the dura, and you can see that these vertebral bodies have been radiated, and this is a lesion that's growing out. This is inside the dura, but outside of the spinal cord. So, the lesion is right here. This is a sagittal T1 with gadolinium. We gave them an agent that will allow this to light up, and that's likely a meningioma. But that is outside of the spinal cord itself, but inside of that protective layer, the hard mother, the dura mater. With regards to coding, for decompression, you always think of the nerve root first. For stabilization, you think of the number of vertebral bodies. Interbody is when we're putting something between the disc spaces, because when you load a graft, that graft will abide by a law that we love, and that's Wolff's Law. Wolff's Law basically means that the bone is going to respond to the stresses placed on it and forces that have been exerted on it. If we lay graft onto the transverse processes, it's not loaded, but bone will still form, and it will still fuse. But we can more reliably achieve a fusion if we load that graft, put it in between the vertebral bodies, and then put some compression on it, and then let the body put compression on it by standing. The fact that there's force being exerted on that graft material will allow Wolff's Law to take place. In the anterior cervical spine, one of the reasons that we have such a high degree of success with anterior cervical operations is because we put an interbody graft there and it has a high degree of fusion rates in the high 90s in non-smokers. Posterolateral fusions do not have the same fusion rates, but they can be performed in combination or in isolation. In 1953, this is a slide from Ralph Cloward. This is remarkable. This is all of the bone. He'd carve these tricortical grafts from the hip, and then he would put it in there and advance it. It's incredible. And then this is circa 2001, where we're using the same geometry, but only using one of them and hoping that it can stabilize. But it does work. Ralph Cloward did all this without using pedicle screws, which is remarkable. This is a posterolateral fusion. Again, the goal is to decorticate the transverse processes, place either bone that had been harvested from that incision or from elsewhere, and also could be mixed with demineralized bone matrix. These are our arthrodesis coat. If we're just doing a posterolateral fusion, a 22612 is what we do if all we do is put in pedicle screws and we place bone graft. This 22630 is when we just do inner body, with no posterolateral fusion. And then when we do them both, the 22633, a combination of both. This is the illustration of the posterolateral fusion, placement of the non-segmental instrumentation and posterolateral fusion with autograft, allograft, with decortication of the transverse process. This is an example of an inner body fusion, where the polymer implant is placed in between the vertebral bodies and non-segmental instrumentation used for fixation. This is the illustration of the posterolateral fusion and an inner body fusion, where the polymer implant is placed in between the vertebral bodies. Placement of the non-segmental instrumentation and posterolateral fusion with autograft, allograft, with decortication of the transverse process. So this is a interoperative footage of transforaminal lumbar inner body fusion done through a minimally invasive approach. And that's the entire fecal sac decompression and instrumentation. So the inner body fusions do require something, whether we put peak bone or metal. This is the illustration of putting an inner body device in position. Then the various bone grafts. We've touched base on that, whether or not we're using allograft, morcellized, structural. And then now, instead of the 22851, we're using the 22853. Bone dolls, we're going to use the 20931. We have titanium cages, which now used to be the 22851, now the 22853, provided our intention is arthrodesis. Peak code, 22853. Whether we use it in the cervical thoracic or lumbar spine, 22853 is what we used to be so familiar with, or 22851. Anterior plating, the 22845, the 4-6, and the 4-7. The number of bodies traversed. Once we go into a three-level cervical fusion, all of a sudden we're up to a 22846. Again, the number of fixation we'll go into. This is an area of confusion, especially in the lumbar spine, because what is non-segmental instrumentation and what is segmental instrumentation? Non-segmental instrumentation can be an L4-5 fusion, where you put pedicle screws into L4 and L5 and connect them. It could also be an L3 to L5 fusion, if you didn't instrument the L4 pedicles because of dysplastic pedicles or because of trauma or tumor. So, you still have two points of fixation. So, it's non-segmental instrumentation. When we're using a single-level corpectomy, 22845, if you use a two-level corpectomy, then you're going to be crossing up levels that would be equivalent to a three-level anterior cervical discectomy with fusion. So, you'd use a 22846. We talked about the various decompression codes, the arthrodesis codes, and the instrumentation codes. These are the instrumentation codes, and I will give you some examples. Once again, the most common one that we use is 22840, non-segmental instrumentation. 22842, this is segmental instrumentation. This is going to be as the numbers of levels go up. This is the 22845. This is going to be the anterior instrumentation codes for the number of levels that we use. Again, if it's one segment, then it will be non-segmental instrumentation. 22841 is kind of a different one because it has to do with spinous process wiring, such as a Brooks-Galley fusion or before how we used to wire spinous processes in the lumbar spine to achieve a fusion. 22842 is now when we begin to go up to the number of more levels, 3-6 vertebrae are being attached. This is 22843, 7-12 vertebral segments. No example using the 22844. Anterior instrumentation, this is putting a big X through both of these because these are erroneously used. The 22845 is not to be used, even though you say, well, I'm using instrumentation. You have to have a separate plate. These are examples of the correct usage of 22845 where a plate was used. We've already discussed these codes. Again, the confusion is two fixation points. Believe it or not, despite all that exposure, that's 22840. That's a Harrington rod treatment for scoliosis. 22840. 22842, 3-6. 22843, 7-12. 22844 is 13 or more. Another code I hope to never use. This is segmental versus non-segmental instrumentation examples. That concludes our section. Thank you, everyone.

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