As more spinal surgery migrates to the outpatient setting, it helps to have a clear understanding of the reimbursement challenges your business staff could face when coding these complicated procedures. This article will help you select the appropriate codes for spinal procedures and optimize reimbursement with modifiers. We'll review three common procedures.

Lumbar laminectomy. One of the most common spinal procedures is the laminotomy (hemilaminectomy) with decompression of nerve roots, including partial facetectomy, foraminotomy and excision of a herniated intervertebral disc; one interspace-lumbar. Code this 63030. When you perform an additional level(s) of the same procedure in the lumbar spine, code the additional level using add-on code 63035. The coding of this procedure is considered unilateral, so if you perform surgery on both sides at the same level, bill it using the bilateral modifier of -50 or -RT/-LT, depending on the payer's preference.

Some of the reasons this procedure would be performed include radiculopathy, stenosis, a displaced intervertebral disc and degenerative disc disease. Diagnostic studies are performed to direct the physician toward treatment options.

During this procedure, the physician makes a small incision over the vertebrae down to the lamina. He then removes the ligament joining the vertebrae and all (ectomy) or part (otomy) of the lamina. The surgeon needs to view the involved nerve root, which he accomplishes by pulling the nerve root back toward the center of the spinal column. The surgeon then removes all or a portion of the disk. This procedure takes around one hour, and minimal bloodloss.

Recovery from this procedure takes up to six months, which includes vigorous physical therapy. Outcomes from this procedure are usually good, provided the patient is careful post-operatively.

Percutaneous vertebroplasty. This procedure is coded 22520 for thoracic and 22521 for lumbar for one vertebral body, and includes a unilateral or bilateral injection at the initial level. If you perform procedures at subsequent levels, use add-on code 22522 for each additional thoracic or lumbar level. Code the fluoroscopic guidance 76012 and use code 76013 if you use CT guidance in the procedure.

Vertebroplasty procedures are performed mostly for osteoporotic compression fractures (which is a condition where a patient's bone density is reduced), or from long-term use of steroids, which make up about 90 percent of the vertebroplasty candidates. The other 10 percent of these patients usually have metastatic lesions, myelomas or hemangiomas.

Under careful fluoroscopic guidance or CT visualization, the physician injects acrylic cement through a needle into the collapsed or weakened vertebra to stabilize the fracture. The needle is advanced into the vertebral body via a transpedicular or parapedicular approach. The procedure doesn't restore the original shape to the vertebra, but it stabilizes the bone, preventing further fracture. The cement sets in less than one hour, and stabilizes and supports the vertebra by forming a hard internal cast.

Percutaneous discectomy. This procedure is indicated for patients who have a contained herniated disk or prolapse and who suffer from radicular back pain (radiates down the leg). Use code 62287, regardless of how it's performed (automated, manual or laser), and regardless of whether it's for single or multiple lumbar levels. Use code 76003 for fluoroscopic guidance.

The patient is placed in a spinal tap position on his left side and C-arm fluoroscopy guides the surgeon to remove a small portion of the intact nucleus pulposus of the disk, where the disk bulge is contained by the nucleus. With the manual technique, the physician inserts one or two needles into the disk, without puncturing the dura. The nucleus pulposus is suctioned out, until the desired decompression is achieved. A surgeon may also use an automated technique (dissecting the disk with a probe and aspirateing it for removal) or laser technique (vaporizing the protruding disc).