How To Use CPT Code 22328

CPT code 22328 describes the open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s) using a posterior approach. 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 22328?

CPT 22328 is used to describe the open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s) using a posterior approach. This code is used when a provider repairs a fracture or dislocation of a vertebra through an incision over the affected vertebra. The procedure typically involves accessing the vertebra, protecting the spinal cord and nerve tissue, reducing the fracture or dislocation, irrigating the area, and closing the incision.

2. Official Description

The official description of CPT code 22328 is: ‘Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment each additional fractured vertebra or dislocated segment (List separately in addition to code for primary procedure).’ This code should be used in conjunction with codes 22325-22327 for the treatment of multiple fractured vertebrae or dislocated segments.

3. Procedure

When performing the open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s) using a posterior approach (CPT 22328), the provider follows a specific procedure:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision over the affected vertebra.
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 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 22328 is used for patients who have a vertebral fracture or dislocation that requires open treatment and/or reduction. This procedure is typically performed when the fracture or dislocation is the result of trauma. It is important to note that CPT 22328 should be used in conjunction with codes 22325-22327 for the treatment of multiple fractured vertebrae or dislocated segments.

5. When to use CPT code 22328

CPT code 22328 should be used when a provider performs the open treatment and/or reduction of a vertebral fracture or dislocation using a posterior approach. This code should be reported once for the first fractured vertebra or dislocated segment, and then separately for each additional fractured vertebra or dislocated segment.

6. Documentation requirements

To support a claim for CPT 22328, the provider must document the following information:

• Patient’s diagnosis of vertebral fracture or dislocation
• Details of the procedure performed, including the specific vertebra or segment treated
• Date of the procedure
• Incision site and approach used
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 22328, ensure that the procedure meets the criteria for open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s) using a posterior approach. This code should be listed separately in addition to the primary procedure code. It is important to note that CPT 22328 should be used in conjunction with codes 22325-22327 for the treatment of multiple fractured vertebrae or dislocated segments.

8. Historical information

CPT 22328 was added to the Current Procedural Terminology system on January 1, 1990. There have been several updates to the code since its addition, including changes to the code description and its inclusion and removal from the Inpatient Only (IPO) list for Medicare billing purposes.

9. Examples

1. A provider performs open treatment and reduction of a fractured vertebra using a posterior approach.
2. A patient sustains a dislocated segment in their vertebral column, and the provider performs open reduction using a posterior approach.
3. A provider treats multiple fractured vertebrae using a posterior approach, performing open treatment and reduction for each segment.
4. A patient presents with a vertebral fracture resulting from trauma, and the provider performs open treatment and reduction using a posterior approach.
5. A provider performs open treatment and reduction of a dislocated segment in the patient’s vertebral column using a posterior approach.
6. A patient requires open treatment and reduction of multiple fractured vertebrae, and the provider performs the procedure using a posterior approach.
7. A provider performs open treatment and reduction of a fractured vertebra using a posterior approach, in addition to performing an arthrodesis for spine fusion.
8. A patient sustains a dislocated segment in their vertebral column, and the provider performs open reduction using a posterior approach, followed by an arthrodesis for spine fusion.
9. A provider treats multiple fractured vertebrae using a posterior approach, performing open treatment and reduction for each segment, and subsequently performing an arthrodesis for spine fusion.
10. A patient presents with a vertebral fracture resulting from trauma, and the provider performs open treatment and reduction using a posterior approach, followed by an arthrodesis for spine fusion.