How To Use CPT Code 22610
CPT code 22610 describes a specific arthrodesis procedure performed on the thoracic 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 22610?
CPT 22610 is a code used to describe a posterior or posterolateral technique arthrodesis procedure performed on a single interspace in the thoracic spine. This procedure involves permanently joining two vertebrae in the upper back to alleviate persistent pain caused by various spinal conditions, such as herniated intervertebral disks, stenosis, and spinal injuries.
2. Official Description
The official description of CPT code 22610 is: ‘Arthrodesis, posterior or posterolateral technique, single interspace thoracic (with lateral transverse technique, when performed).’ This code specifically refers to the fusion of two vertebrae in the thoracic spine using a posterior or posterolateral technique.
3. Procedure
During the arthrodesis procedure described by CPT 22610, the healthcare provider makes a midline incision over the affected thoracic vertebrae in the upper back. They then dissect through the subcutaneous tissue and muscles to visualize the bone. The provider strips the muscles from the spinous process and posterior lamina out to the mid-portion of the facet joints. Decortication, the removal of the outer layer of the bone, is performed using bone cutting instruments. Bone graft material is applied to the prepared bony surfaces at the back of the vertebrae, at the back and side, or at the side and across (lateral transverse). Metal implants may also be inserted to hold the vertebrae together until new bone grows between them. The muscles and ligaments are sutured over the grafted areas, and the incision is closed. A brace or immobilization device may be applied post-procedure.
4. Qualifying circumstances
CPT 22610 is used for patients who require arthrodesis in the thoracic spine due to conditions such as herniated intervertebral disks, stenosis, or spinal injuries. The procedure is performed by a healthcare provider and involves the fusion of two vertebrae using a posterior or posterolateral technique. The specific qualifying circumstances may vary depending on the patient’s medical history and the provider’s clinical judgment.
5. When to use CPT code 22610
CPT code 22610 should be used when a healthcare provider performs a posterior or posterolateral technique arthrodesis procedure on a single interspace in the thoracic spine. This code is appropriate for cases where fusion of two vertebrae is necessary to alleviate persistent pain caused by specific spinal conditions. It is important to review the documentation and clinical circumstances to ensure accurate coding.
6. Documentation requirements
To support a claim for CPT 22610, the healthcare provider must document the following information:
- Patient’s diagnosis and the medical necessity for the arthrodesis procedure
- Details of the procedure performed, including the specific technique used (posterior or posterolateral)
- Location of the fusion (single interspace thoracic)
- Any additional procedures or techniques performed, such as lateral transverse technique
- Start and end time of the procedure
- Any bone graft material used and its source
- Use of metal implants, if applicable
- Post-procedure care instructions, including the use of a brace or immobilization device
- Signature of the healthcare provider performing the procedure
7. Billing guidelines
When billing for CPT 22610, ensure that the procedure performed meets the criteria specified in the code description. It is important to accurately document the specific technique used (posterior or posterolateral) and any additional procedures or techniques performed, such as the lateral transverse technique. Review coding and payer guidelines to determine if graft harvesting can be reported separately. It is also essential to follow any specific billing guidelines provided by the payer or regulatory authorities.
8. Historical information
CPT code 22610 was added to the Current Procedural Terminology system on January 1, 1990. Since then, 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. It is important to stay updated with the latest coding guidelines and any changes to CPT code 22610.
9. Similar codes to CPT 22610
There are several similar codes to CPT 22610 that describe arthrodesis procedures on the spine. These include:
- CPT 22590: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic
- CPT 22595: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar
- CPT 22600: Arthrodesis, posterior or posterolateral technique, single interspace, lumbar
- CPT 22612: Arthrodesis, posterior or posterolateral technique, single interspace, lumbar (with lateral transverse technique, when performed)
- CPT 22614: Arthrodesis, posterior or posterolateral technique, single interspace, lumbar (with interbody technique, transforaminal lumbar interbody fusion, or axial lumbar interbody fusion, when performed)
9. Examples
- A patient with a herniated intervertebral disk in the thoracic spine undergoes a posterior arthrodesis procedure on a single interspace using CPT code 22610.
- A healthcare provider performs a posterolateral technique arthrodesis on a single interspace in the thoracic spine for a patient with spinal stenosis, using CPT code 22610.
- A patient with a spinal injury requires a posterior arthrodesis procedure on a single interspace in the thoracic spine, which is coded using CPT 22610.
