Reinsertion (22849) vs. Segmental (22842) Instrumentation

Question:

I have a question about reinsertion of spinal instrumentation vs posterior segmental instrumentation. We have a patient who our neurosurgeon performed an exploration previous L4-S1 fusion with removal of rods bilaterally, L3-L4 laminectomy with PLIF and posterolateral fusion with placement of pedicle screws at L3 and new rods from L3-S1.

I have researched and would like to verify if we could bill the CPT 22849 for replacement of the instrumentation from L4-S1 plus CPT 22842 for the new pedicle screws and rods. I spoke to a coding hotline who said 22849 and 22842 were accurate but I thought I better check with an expert – you!

Answer:

I’m so glad you asked because you’ve been give inaccurate advice. CPT 22849 is reported when you remove and replace instrumentation at the exact same level(s); in this case you extended the instrumentation so 22849 does not apply. When you extend the instrumentation meaning adding it to an adjacent level, you report only the “new code” such as 22842.

*This response is based on the best information available as of 06/08/17.