How To Use CPT Code 22326

CPT code 22326 describes the open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s) using a posterior approach for one fractured vertebra or dislocated segment in the cervical spine. 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 22326?

CPT 22326 is used to describe the open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s) in the cervical spine. This code specifically applies to cases where there is one fractured vertebra or dislocated segment. The procedure involves accessing the affected area through an incision at the back of the neck and performing the necessary repairs or reductions to restore normal anatomy.

2. Official Description

The official description of CPT code 22326 is: ‘Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment cervical.’

3. Procedure

The procedure for CPT 22326 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision over the affected vertebra at the back of the neck.
3. The provider dissects through the fascia and muscle to visualize the fractured or dislocated segment.
4. The provider resects the bone to protect the theca, or covering of the spinal cord, and any nerve tissue.
5. The provider then reduces the fracture or dislocation using surgical tools.
6. The provider irrigates the area, checks for bleeding, removes any instruments, and closes the incision.

4. Qualifying circumstances

CPT 22326 is used when there is a fracture or dislocation of a cervical vertebra in the neck. This typically occurs as a result of trauma to the neck. The procedure is performed using a posterior approach, accessing the affected area through an incision at the back of the neck. It is important to note that CPT code 22326 should not be reported in conjunction with codes 22510 and 22512 when performed at the same level.

5. When to use CPT code 22326

CPT code 22326 should be used when a provider performs open treatment and/or reduction of a vertebral fracture or dislocation in the cervical spine using a posterior approach. This code specifically applies to cases involving one fractured vertebra or dislocated segment. It is important to review the documentation and confirm that the procedure meets the specific criteria outlined in the code description before reporting CPT 22326.

6. Documentation requirements

To support a claim for CPT 22326, the provider must document the following information:

• Patient’s diagnosis indicating the presence of a vertebral fracture or dislocation
• Details of the procedure performed, including the specific vertebra or segment involved
• Description of the surgical approach used (posterior approach)
• Incision site and size
• Steps taken to protect the theca and nerve tissue
• Details of the reduction or repair performed
• Confirmation of irrigation, hemostasis, and closure

7. Billing guidelines

When billing for CPT 22326, it is important to ensure that the procedure meets the specific criteria outlined in the code description. CPT code 22326 should not be reported in conjunction with codes 22510 and 22512 when performed at the same level. It is also important to review any additional guidelines or requirements from payers to ensure accurate and appropriate billing.

8. Historical information

CPT code 22326 was added to the Current Procedural Terminology system on January 1, 1990. There have been several historical changes to the code, including updates to the code description and its inclusion or exclusion from the Inpatient Only (IPO) list for Medicare billing purposes.

9. Examples

1. A patient presents with a fractured vertebra in the cervical spine following a car accident. The provider performs open treatment and reduction of the fracture using a posterior approach. CPT code 22326 would be used to report this procedure.
2. A patient sustains a dislocated segment in the cervical spine due to a fall. The provider performs open treatment and reduction of the dislocation using a posterior approach. CPT code 22326 would be used to report this procedure.
3. A patient is involved in a sports-related injury and fractures a vertebra in the cervical spine. The provider performs open treatment and reduction of the fracture using a posterior approach. CPT code 22326 would be used to report this procedure.
4. A patient presents with a dislocated segment in the cervical spine following a traumatic event. The provider performs open treatment and reduction of the dislocation using a posterior approach. CPT code 22326 would be used to report this procedure.
5. A patient is involved in a motor vehicle accident and sustains a fractured vertebra in the cervical spine. The provider performs open treatment and reduction of the fracture using a posterior approach. CPT code 22326 would be used to report this procedure.