CPT 22551 refers to an anterior cervical discectomy and fusion procedure, which involves the removal of a cervical disc and stabilization of the vertebrae. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT code 22551.
1. What is CPT 22551?
CPT 22551 is a medical code used to describe an anterior cervical discectomy and fusion (ACDF) procedure. This surgical procedure involves the removal of a cervical disc through the front of the neck to alleviate spinal pain and related symptoms. The vertebrae are then stabilized through fusion to prevent further complications.
2. 22551 CPT code description
The official description of CPT code 22551 is: “Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2.”
The 22551 procedure involves the following steps:
- Administration of anesthesia and patient preparation.
- Transverse incision made anteriorly over the level of the arthrodesis target site.
- Platysma muscle cut and prevertebral fascia cleared from the front of the spine.
- Identification and exposure of the target disc, possibly using X-ray.
- Utilization of traction devices.
- Removal of portions of the disc by cutting the surrounding fibrous ring (annulus fibrosis) and removing the disc’s inner core (nucleus pulposus).
- Decompression of the spinal cord and/or nerve roots.
- Possible removal of the posterior longitudinal ligament and bone spurs (osteophytes).
- Insertion of bone graft material for fusion.
- Closure of the surgical site.
4. Qualifying circumstances
Patients eligible to receive CPT code 22551 services are those experiencing spinal pain and related symptoms due to cervical disc issues. These symptoms may include neck pain, arm pain, numbness, tingling, or weakness. The procedure is typically recommended for patients who have not responded to conservative treatments such as physical therapy, medications, or injections.
5. When to use CPT code 22551
It is appropriate to bill the 22551 CPT code when a patient undergoes an anterior cervical discectomy and fusion procedure for the treatment of spinal pain and related symptoms caused by cervical disc issues. The code should be used for the primary level of fusion, with additional levels billed using the add-on code +22552.
6. Documentation requirements
To support a claim for CPT 22551, the following information should be documented:
- Patient’s medical history and symptoms.
- Conservative treatments attempted and their outcomes.
- Diagnostic imaging results, such as X-rays, MRI, or CT scans.
- Operative report detailing the procedure, including the specific steps taken, materials used, and levels fused.
- Postoperative care plan and follow-up appointments.
7. Billing guidelines
When billing for CPT code 22551, it is essential to follow the appropriate guidelines and rules. These may include:
- Using the add-on code +22552 for each additional interspace affected.
- Ensuring proper documentation is in place to support the claim.
- Verifying insurance coverage and obtaining any necessary pre-authorizations.
- Staying up-to-date with any changes to coding guidelines or reimbursement rates.
8. Historical information
CPT 22551 was added to the Current Procedural Terminology system on January 1, 2011. There have been no updates to the code since its addition.
9. Similar codes to CPT 22551
Five similar codes to CPT 22551 include:
- CPT 22552: This add-on code is used for each additional interspace affected during the same procedure.
- CPT 22554: This code refers to an anterior fusion procedure without discectomy or decompression.
- CPT 22556: This code describes a posterior cervical fusion procedure.
- CPT 22558: This code is used for lumbar interbody fusion procedures.
- CPT 22585: This add-on code is used for each additional interspace affected during a lumbar interbody fusion procedure.
Here are 10 detailed examples of CPT code 22551 procedures:
- A 45-year-old patient with severe neck pain and arm numbness undergoes an ACDF at the C5-C6 level.
- A 55-year-old patient with cervical spinal stenosis undergoes an ACDF at the C3-C4 level to alleviate symptoms.
- A 60-year-old patient with a herniated cervical disc at the C6-C7 level undergoes an ACDF to relieve pain and weakness.
- A 50-year-old patient with degenerative disc disease at the C4-C5 level undergoes an ACDF to improve neck pain and function.
- A 40-year-old patient with a cervical disc bulge at the C5-C6 level undergoes an ACDF after conservative treatments fail to provide relief.
- A 65-year-old patient with cervical spondylosis undergoes an ACDF at the C3-C4 and C4-C5 levels to alleviate symptoms.
- A 70-year-old patient with cervical radiculopathy undergoes an ACDF at the C6-C7 level to relieve arm pain and weakness.
- A 35-year-old patient with a cervical disc herniation at the C5-C6 level undergoes an ACDF after conservative treatments fail to provide relief.
- A 48-year-old patient with cervical foraminal stenosis undergoes an ACDF at the C4-C5 level to alleviate symptoms.
- A 52-year-old patient with a cervical disc herniation at the C6-C7 level undergoes an ACDF to relieve neck pain and arm numbness.