How To Use CPT Code 21610

CPT 21610 describes the costotransversectomy procedure, which involves the removal of a piece of rib and the transverse process of the vertebra to relieve back pain caused by compression of spinal nerves. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21610?

CPT 21610 is a code used to describe the costotransversectomy procedure. This procedure involves the removal of a piece of rib and the transverse process of the vertebra, which is the bony projection to which the rib connects. The purpose of this procedure is to alleviate back pain that is caused by the compression of spinal nerves.

2. Official Description

The official description of CPT code 21610 is: ‘Costotransversectomy (separate procedure).’ This code is used to report the excision of a rib and the transverse process of the vertebra to relieve back pain caused by the compression of spinal nerves.

3. Procedure

The costotransversectomy procedure involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. An incision is made over the rib that needs to be excised.
3. The paravertebral muscles are divided horizontally.
4. The costotransverse joints and transverse processes are cleared of their muscle attachments.
5. The periosteum of the rib is incised and stripped from the costotransverse joint.
6. The rib is cut from the joint using a bone cutting tool.
7. The ligaments of the costotransverse joint are severed, and the rib is removed.
8. The transverse process is removed with bone cutting tools to access the intervertebral foramen.
9. The lateral surface of the vertebral body is exposed.
10. The area is irrigated, checked for bleeding, and drainage tubes may be placed.
11. The incision is closed in layers.

4. Qualifying circumstances

CPT 21610 is performed on patients who experience back pain due to the compression of spinal nerves. The procedure is indicated when other conservative treatments have failed to provide relief. It is important to note that this procedure is a separate procedure and should not be reported if it is performed as part of another procedure.

5. When to use CPT code 21610

CPT code 21610 should be used when the costotransversectomy procedure is performed as a separate procedure to relieve back pain caused by the compression of spinal nerves. It should not be reported if it is performed as part of another procedure.

6. Documentation requirements

To support a claim for CPT 21610, the following documentation is required:

• Patient’s diagnosis of back pain caused by the compression of spinal nerves
• Description of the costotransversectomy procedure performed
• Date of the procedure
• Details of the incision, removal of rib and transverse process, and closure of the incision
• Any additional procedures performed during the same operative session
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21610, ensure that the procedure is performed as a separate procedure and not as part of another procedure. It is important to follow the specific guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT 21610 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient with chronic back pain undergoes a costotransversectomy procedure to relieve the compression of spinal nerves.
2. A patient with a history of failed conservative treatments for back pain undergoes a costotransversectomy procedure as a separate procedure.
3. A patient with a diagnosis of spinal nerve compression undergoes a costotransversectomy procedure to alleviate back pain.
4. A patient with radiating back pain undergoes a costotransversectomy procedure to relieve the compression of spinal nerves.
5. A patient with persistent back pain undergoes a costotransversectomy procedure as a separate procedure.
6. A patient with a diagnosis of spinal nerve compression undergoes a costotransversectomy procedure to alleviate back pain.
7. A patient with chronic back pain undergoes a costotransversectomy procedure to relieve the compression of spinal nerves.
8. A patient with a history of failed conservative treatments for back pain undergoes a costotransversectomy procedure as a separate procedure.
9. A patient with a diagnosis of spinal nerve compression undergoes a costotransversectomy procedure to alleviate back pain.
10. A patient with radiating back pain undergoes a costotransversectomy procedure to relieve the compression of spinal nerves.