An in-depth overview of Lumbar Spinal Fusion – Learn about the coding updates and documentation requirements for spinal fusion procedures.

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2. Spinal Arthrodesis - a
Billable Procedure
 Lumbar spinal fusion is a surgical procedure
performed to fuse together the painful vertebrae so
that they heal into a single, solid bone
 Orthopedic surgeons perform spinal fusion surgery
or spinal arthrodesis to restrict spinal motion in
order to relieve painful symptoms.
 Orthopedics medical billing involves preparation of
medical documentation with the updated spine
codes published by the Centers for Medicare and
Medicaid Service (CMS).
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3. Documentation Requirements
 Approval of claims entailing major procedures
requires documentation supporting the
reasonableness and necessity of the procedure.
 Physicians must make sure that the submitted
documentation includes
 History and Physical
 Duration/character/location/radiation of pain
 Activity of daily living (ADL) limitations
 Physical examination
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4. CPT Coding for Spinal
Arthrodesis
 It is critical for practices to report the correct CPT
arthrodesis code(s), based on whether the
approach was posterior or anterior.
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CPT codes for Posterior
Lumbar
 “Posterior, Posterolateral or Lateral Transverse
Process Technique Arthrodesis Procedures on
the Spine (Vertebral Column)”
22612, +22614, 22630, +22632, 22633, +22634

5. Codes for Anterior Lumbar
 Anterior or Anterolateral Approach Technique
Arthrodesis Procedures on the Spine (Vertebral
Column)
- 22558, +22585
 For anterior approach to reach the damaged
vertebrae, with an incision made through the
neck for cervical vertebrae
- 22554 Arthrodesis, anterior interbody technique,
including minimal discectomy to prepare
interspace (other than for decompression);
cervical below C2
 For resection of a single vertebral body
- 63081 Vertebral corpectomy (vertebral body
resection), partial or complete, anterior approach
with decompression of spinal cord and/or nerve
root(s); cervical, single segment
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6. Codes for Primary Procedure
 If the physician prepared and inserted an allograft
- +20931 Allograft, structural, for spine surgery only
 For the anterior instrumentation of two to three
vertebral segments
- +22845 Anterior instrumentation; 2 to 3 vertebral
segments
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7. Lateral
 For the initial thoracic level the surgeon treats
using lateral extracavitary approach
- 22532 Arthrodesis, lateral extracavitary
technique, including minimal discectomy to
prepare interspace (other than decompression);
thoracic
 For each additional level the surgeon treats beyond
the initial thoracic level, report add-on code
- +22534 Arthrodesis, lateral extracavitary
technique, including minimal discectomy to
prepare interspace (other than decompression);
thoracic or lumbar, each additional vertebral
segment
 For procedures contained to the lumbar region
- 22533 Arthrodesis, lateral extracavitary technique,
including minimal discectomy to prepare
interspace (other than decompression); lumbar
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8. CONTACT
 Professional medical billing and coding companies
provide the services of experienced medical coders.
 Medical coders review the operative notes to
determine where the instrument was used, and
whether it was non-segmental, segmental, or
intervertebral and assign the correct medical codes.
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Tulsa, OK 74133
Main: (800) 670 2809
Fax: (877) 835-5442
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