How To Use CPT Code 0095T

CPT 0095T describes a specific procedure for the removal of a total disc arthroplasty (artificial disc) in the cervical spine. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0095T?

CPT 0095T can be used to describe the removal of an additional artificial disc in the cervical spine during the same operative session as the initial disc removal. This code is an add-on procedure and should be reported in conjunction with the primary code, 22861.

2. Official Description

The official description of CPT code 0095T is: ‘Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure).’ This code should be used in conjunction with code 22861.

3. Procedure

1. The provider uses an anterior approach to access the site for disc removal in the cervical spine.
2. After incising the front of the neck, the provider dissects through the scar tissue of the original incision to expose the prevertebral space.
3. Retractors are used to hold back the tissues, and the provider identifies the target segment for disc removal.
4. The provider removes the artificial disc and achieves hemostasis.
5. After the initial disc removal, the provider identifies another target segment for the removal of an additional artificial disc.
6. The provider separates the bone surfaces, loosens the arthroplasty device from any adhesions, debrides the area, and removes the device.
7. Hemostasis is achieved, all retractors are released from surrounding muscles, and all tissue and muscle are reapproximated.
8. Drains are placed, the incision is closed in layers, and a sterile dressing is applied.

4. Qualifying circumstances

CPT 0095T is used when an additional artificial disc is removed in the cervical spine during the same operative session as the initial disc removal. This procedure is typically performed to treat conditions such as degenerative disc disease or damage due to trauma.

5. When to use CPT code 0095T

CPT code 0095T should be used when an additional artificial disc is removed in the cervical spine during the same operative session as the initial disc removal. It is important to report this code in conjunction with the primary code, 22861, to accurately reflect the complete procedure.

6. Documentation requirements

To support a claim for CPT 0095T, the provider must document the following information:

• Indication for the removal of the additional artificial disc
• Details of the anterior approach used
• Identification of the target segments for disc removal
• Specific steps taken during the procedure, including separation of bone surfaces, loosening of the arthroplasty device, debridement, and removal of the device
• Hemostasis achieved
• Release of retractors from surrounding muscles
• Reapproximation of all tissue and muscle
• Placement of drains, closure of the incision, and application of a sterile dressing

7. Billing guidelines

When billing for CPT 0095T, it is important to report this code in conjunction with the primary code, 22861. This is an add-on code, and it must be reported with the appropriate primary code. Ensure that the documentation supports the medical necessity of the procedure and accurately reflects the steps taken during the removal of the additional artificial disc.

8. Historical information

CPT 0095T was added to the Current Procedural Terminology system on January 1, 2006. There have been several changes to the code since its addition, including updates to the description and the addition of notes regarding its use in conjunction with other codes.

9. Examples

1. A surgeon removes an additional artificial disc in the cervical spine during the same operative session as the initial disc removal to treat degenerative disc disease.
2. A patient undergoes a procedure in which an additional artificial disc is removed in the cervical spine to address damage caused by trauma.
3. A provider performs the removal of an additional artificial disc in the cervical spine during the same operative session as the initial disc removal to alleviate symptoms of a herniated disc.
4. An individual undergoes a procedure in which an additional artificial disc is removed in the cervical spine to address complications from a previous disc replacement surgery.
5. A surgeon performs the removal of an additional artificial disc in the cervical spine during the same operative session as the initial disc removal to improve the patient’s range of motion and alleviate pain.
6. A patient undergoes a procedure in which an additional artificial disc is removed in the cervical spine to address complications from a previous spinal fusion surgery.
7. A provider performs the removal of an additional artificial disc in the cervical spine during the same operative session as the initial disc removal to treat recurrent symptoms of degenerative disc disease.
8. An individual undergoes a procedure in which an additional artificial disc is removed in the cervical spine to address complications from a previous artificial disc replacement surgery.
9. A surgeon performs the removal of an additional artificial disc in the cervical spine during the same operative session as the initial disc removal to address ongoing pain and limited mobility.
10. A patient undergoes a procedure in which an additional artificial disc is removed in the cervical spine to address complications from a previous spinal trauma.