Coding Corner

Matthew D. Hepler, MD
Coding Committee Past Chair

Coding for Intervertebral Biomechanical Devices:
Recent changes and their impact

Intervertebral fusion has been performed with autograft, allograft, and biomechanical devices usually made of synthetic materials including PEEK and metals, most commonly Titanium. The primary goal of intervertebral fusion with any of these materials is to maintain or restore disc height and alignment while promoting spinal arthrodesis.  The use of intervertebral mechanical devices has increased dramatically in recent years as have implant design and fixation techniques ultimately leading to a revision in the codes used to describe them. This article will review coding for intervertebral biomechanical devices, outline the recent changes that have been implemented, and some of the nuances associated with their use. This article only discusses the use of biomechanical devices as coding with bone graft materials has not changed.

Prior to 2017, placement of intervertebral biomechanical devices was reported with CPT code 22851.

22851: Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methymethacrylate) to vertebral defect or interspace (list separately in addition to code for primary procedure)

This procedure was used most commonly in anterior cervical and lumbar interbody fusion procedures. The utilization of 22851 expanded dramatically as it came to include a growing number of PLIF, TLIF, ALIF, XLIF, and DLIF procedures. The increased utilization of 22851 came to the attention of Centers for Medicare and Medicaid Services (CMS) which led to a review by the AMA Relative Value Update Committee (RUC).
Nonetheless, the utilization of 22851 continued to rise from 45,175 in 2005 to 126,885 in 2015 while payments increased to $50,144,684. Due to this growing utilization and high expenditure the RUC recommended review of the code by specialty societies including the American Association of Neurological Surgeons (AANS), the Congress of Neurological Surgeons (CNS), the American Academy of Orthopaedic Surgeons (AAOS), and the North American Spine Society (NASS). Based on this survey the RUC and specialty societies determined 22851 no longer accurately described the various ways in which the devices were currently used. One area of particular confusion was the growing trend of employing intervertebral biomechanical devices with integral fixation (screws or flanges) and reporting anterior instrumentation (22845-22847) with 22851. Due to these concerns the RUC and specialty societies subsequently referred the code to the AMA Current Procedural Terminology (CPT) Editorial Panel to create new codes for the devices.

In 2016 the CPT panel, in association with representatives from various specialty societies, created three new codes to replace 22851. Effective January 1, 2017, 22851 was deleted from the code set and replaced with the following three codes for insertion of biomechanical devices:

22853 Insertion of interbody biomechanical device(s) (eg. synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges) when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace

22854 Insertion of interbody biomechanical device(s) (eg. synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges) when performed, to vertebral corpectomy (ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect

22859 Insertion of interbody biomechanical device(s) (eg. synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect

These new codes are add on codes, reported per level, and not subject to the 51 multiplier procedure modifier. These codes are also inclusive of any “integral anterior fixation” such as flanges and screws which typically pass through the device and are used to anchor the biomechanical device to the vertebral body. The purpose, biomechanical design, and work involved with device anchoring is bundled into these codes and distinct and separate from anterior instrumentation used to stabilize the vertebral column (22845-22847).

Code 22853
This code is typically reported for various interbody fusion procedures when an invertebral biomechanical device is inserted to fill the discectomy defect. This might include anterior lumbar interbody fusion (ALIF), direct lumbar interbody fusion (DLIF), extreme lateral interbody fusion (XLIF), posterior lumbar interbody fusion (PLIF), transforaminal interbody fusion (TLIF), and anterior cervical discectomy and fusion (ACDF) procedures. Work includes preparation or templating the endplates and insertion of the device including any fixation “integral” to the device. Generally, the device height would correspond to disc height (cervical 5-7mm, lumbar 10mm) although some devices are designed with various degrees of lordosis to facilitate restoration of lordosis.

Code 22854
This code is reported for fusion procedures when a biomechanical device is inserted to fill or replace a corpectomy defect. A corpectomy defect usually includes discectomy of the level above and below the vertebral body that is removed and involves resection of a minimum of 1/3 (lumbar) to ½ (cervical) of the vertebral body. The mechanical device is inserted into the defect engaging the inferior endplate of the cephalad vertebral body and the superior endplate of the inferior vertebral body. For this reason a device used to fill a corpectomy defect would likely measure >2cm in the cervical spine and >5 cm in the lumber spine.

Code 22859
This code is reported for the unique situation where a biomechanical device is inserted in a defect and a spinal fusion is not being performed. The most common scenario is a spinal infection or tumor treated with discectomy or corpectomy and placement of a biomechanical device into the defect to stabilize the segment. This could be a temporary solution to allow for post op radiation therapy or repeat I+D before returning for a definitive fusion procedure or it could be done for palliative treatment where a fusion isn’t planned. Again, the use of integral fixation to anchor the device to the vertebral body is inclusive to this code.

Anterior Instrumentation and biomechanical device codes.
As discussed earlier part of the reason for developing new codes was to distinguish the role and coding of instrumentation “integral” to the device and used to anchor the device to the vertebral body from instrumentation used to stabilize the spine (22845-22847). Many device manufactures had developed various instrumentation techniques including small mini plates, flanges, and screws to anchor the device to the vertebral body. The use of such devices and the work of inserting them is bundled into the new codes and it’s inappropriate to report anterior instrumentation codes for them.
Anterior instrumentation (22845-22847) on the other hand are stand alone devices which are designed and manufactured to biomechanically stabilize an unstable spine following discectomy, corpectomy, osteotomy, or deformity correction. They include plates, rods, and screws and can be used as stand alone instrumentation or in combination with various allograft, autograft or biomechanical device implants. Anterior instrumentation must span any defect to the vertebra above and below. They are not “integral” to biomechanical devices, are not bundled into their codes (22853, 22854, 22859) and can be reported separate from or in addition to them when used.
Nonetheless, CMS and the National Correct Coding Initiative (NCCI) interpreted the codes 22853 and 22854 as being inclusive of anterior instrumentation. They subsequently implemented an NCCI edit April 1 2017 for the device codes (22853-22854) excluding their use with anterior instrumentation codes (22845-22847). They do however, allow use of modifier 59 to bypass these edits if a provider uses additional anterior instrumentation unrelated to the anchoring device.  For example an anterior corpectomy C5 with C4-6 fusion and instrumentation utilizing a biomechanical device would be coded 63081, 22554, 22585, 22854, 22845-59. The use of a structural allograft/autograft instead of the biomechanical device does not trigger the NCCI edit and denial and does not require modifier 59.

Its worth noting that the original biomechanical device code 22851 was valued at 6.70 RVUs. During the process of creating the new codes the AMA RUC determined new values based on member surveys which CMS then revised down to 4.25 and 5.50 for 22853 and 22859 respectively. This tendency for code re-evaluation to result in a decrease in RVU value is not uncommon and remains a prominent concern anytime a spine code or family of codes gains attention for reconsideration.

References:
Blasier D., Cheng J., Mitchell W., et al. Coding for Spinal Interbody Biomechanical Cages and Devices. Spineline.March 2017 pp
Liz Vogt. A Closer Look at Biomechanical Cage and Device Coding. ISASS. Nov 21, 2017.
Zhou SH, McCarthy AD, McGregor AH, et al. Geometric dimensions of the lower lumbar vertebra. Eur Spine J 2000. 9:242-248
Mehta HP, Santos ER, Sembrano JN et al. Radiographic Measurement of cervical disc height and inter-surgeon variability in its application. ORS 2012. Poster No 2192

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Chair: Barton L. Sachs Committee: Mathew D. Hepler, Past Chair, Advisory; William K. Koeck (C); Kathryn McCarthy Mullooly (C); Matthew E. Oetgen (C); Michael S. Chang; Walaa Elassuity; R. Dale Blasier, Advisory; John Frino