Q&A: CPT coding for an anterior cervical discectomy and fusion
Q: What CPT codes would you use to report an anterior cervical discectomy and interbody fusion performed at the same level during the same session?
If two surgeons perform the procedures separately, would it be appropriate to report code 22554 (arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2) in conjunction with code 63075 (discectomy, anterior, with decompression of spinal cord and/or nerve roots, including osteophytectomy; cervical, single interspace)?
A: No. Per the CPT guidelines, coders should not report 22554 in conjunction with 63075, even if these procedures are performed by separate providers. Coders should instead report all-encompassing CPT code 22551 (arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) for an anterior cervical discectomy and interbody fusion performed at the same level during the same session.
If two physicians performed the discectomy and arthrodesis, they must each report 22551 with modifier -62 (two surgeons). In some cases, it would be appropriate to report 22551 with one or more units of add-on code 22552 (…; each additional interspace), to indicate work was done on one or more additional interspaces. Code 22551 and add-on code 22552 include fluoroscopic guidance and the use of a microscope.
Editor’s note: This question was answered by Lynn Anderanin CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois.
This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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