Claim denials are a challenge that every medical professional faces once in their lifetime! But have you ever wondered what the reason for these denials might be? These denials often occur from missing small details in your documents, incorrect modifiers, or incorrect code application.
Hence, we have decided to discuss details about various CPT codes in our blogs. Here we will discuss the CPT code 22612, which refers to lumbar spinal fusion. It is a relatively uncommon surgical process. However, in the USA, approximately 1.6 million spinal fusions are performed annually.
Among these million surgeries, half of the surgeons must have faced issues with the billing of this procedure. So, here is a thorough guide to help you understand the code and bill it accurately!
CPT Code 22612 – Description
CPT code 22612 refers to a surgical treatment known as arthrodesis (also called spinal fusion). In this procedure, the physician permanently fuses two vertebrae in the lumbar spine (lower back).
He uses bone graft material to fuse the spine at the rear of the vertebrae, the back and side, or the side and crosswise. This is done to limit mobility between two or more vertebrae and reduce discomfort or correct a spinal abnormality.
Scenarios Where CPT Code 22612 is Applicable
Let’s understand the CPT code 22612’s accurate application with some real-life examples.
Degenerative Disc Disease
Let’s say a 52-year-old construction worker has had persistent low back discomfort for over five years. His pain worsened after years of heavy lifting, making it difficult for him to stand for extended periods of time. Imaging investigations showed instability at the L4-L5 level and significant disc degeneration. He attempted several therapies, but they only provided short-term respite. The optimum course of action, according to his orthopaedic spine surgeon, was surgery.
In order to stabilize the vertebrae and prevent mobility at the afflicted level, a posterior lumbar fusion (arthrodesis) was carried out utilizing bone graft material. Hence, for this single-level lumbar fusion, CPT code 22612 was used for documentation and billing.
Spinal Instability
A 38-year-old man had a lumbar spine fracture after being involved in a car accident. He was originally treated with various pain-relieving medications, but his lower back pain stayed. His imaging examinations revealed micro-movements between the broken vertebrae and inadequate healing.
The orthopaedic surgeon chose to perform an arthrodesis to stabilize the wounded area and encourage fast recovery. Therefore, he can bill this single-level lumbar fusion with CPT code 22612.
Nerve Compression
Imagine a 60-year-old teacher experienced sharp shooting pain starting from her lower back to her right leg. After months of discomfort, her MRI revealed that her vertebra slipped out of place, causing nerve compression. Initially, healthcare providers tried non-surgical options, but they failed to provide her relief. Then, finally, her neurosurgeon performed a posterior lumbar arthrodesis to stabilize the slipped vertebra and relieve the pressure on the spinal nerves.
He used bone grafts and pedicle screws to hold the vertebrae in correct alignment while fusion occurred. This surgical procedure can be billed with CPT code 22612 to describe the lumbar fusion procedure performed at a single level.
Applicable Modifiers for CPT Code 22612
The following are some modifiers that may be applied to CPT code 22612 according to the respective situation.
Modifier 22
Modifier 22 refers to increased services. You can apply this modifier if the surgeon spent more time and effort on the procedure compared to the standard. This may occur in the cases of challenging anatomy. However, it is essential to back this modifier with documentation.
Modifier 62
Modifier 62 refers to the services of two co-surgeons. Hence, you can apply this modifier with CPT code 22612 when two surgeons perform the surgery as co-surgeons, each executing a separate and essential portion of the procedure.
Modifier 80
You may also apply modifier 80 with CPT code 22612 if there was an involvement of an assistant surgeon. However, you must clinically justify his role and prove it through your documents.
CPT Code 22612 – Billing & Reimbursement Guidelines
The following are some essential billing and reimbursement guidelines that you must fulfill while filing claims for CPT code 22612.
Understand the Correct Application of 22612
You must remember that CPT code 22612 applies solely to the lumbar region. Therefore, if the spinal arthrodesis was performed in the thoracic or cervical regions, use other CPT codes like 22610 or 22600
Provide Comprehensive Documentation
Your proper paperwork provides proof of your service to the insurance payer. Hence, while billing for CPT code 22612, documents play a major role in reimbursement.
For example, Medicare will only provide coverage and payment for lumbar spinal fusion if it is proven to be reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body part. Furthermore, it also requires that your documentation proves that the patient fulfilled at least one of the criteria for the procedure as outlined in their LCD document.
Follow the Payers’ Policies
Besides Medicare, there are numerous other insurance payers in the USA, each with its own specific guidelines. Therefore, prior to filing those claims for reimbursement, it is advisable to confirm that you are adhering to their policies.
Bottom Line
CPT code 22612 pertains to arthrodesis for one interspace in the lumbar area. As it is a surgical procedure, you can apply modifiers designated for co-surgeons or assistant surgeons.
We have discussed nearly all critical details regarding this code’s billing and reimbursement practices. But if you still find any ambiguity, you may contact a neurosurgery billing services provider for your assistance. These experts can help you resolve all the billing challenges that you might be facing.
