How To Use CPT Code 22852

CPT 22852 describes the removal of a previously implanted segmental spinal instrumentation device from the posterior portion of the 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 22852?

CPT 22852 is used to describe the removal of a previously implanted segmental spinal instrumentation device from the posterior portion of the spine. This code is used when the provider removes the device due to infection, pain, rejection, or failure.

2. Official Description

The official description of CPT code 22852 is: ‘Removal of posterior segmental instrumentation.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes a longitudinal incision over the affected area.
3. The surrounding muscles and tissues are dissected to expose the instrumentation completely.
4. The screws and/or other fixation from each vertebral segment are removed and detached.
5. The area is irrigated with antibiotics, checked for bleeding, and any instruments are removed.
6. The incision is closed.

4. Qualifying circumstances

CPT 22852 is performed when a previously implanted segmental spinal instrumentation device needs to be removed due to infection, pain, rejection, or failure. The procedure is typically performed by a qualified healthcare provider.

5. When to use CPT code 22852

CPT code 22852 should be used when a provider is removing a previously implanted segmental spinal instrumentation device from the posterior portion of the spine. It is important to ensure that the removal is necessary due to infection, pain, rejection, or failure of the device.

6. Documentation requirements

To support a claim for CPT 22852, the provider must document the following information:

• Reason for removal (infection, pain, rejection, or failure)
• Details of the procedure, including the incision, dissection, removal of screws or fixation, irrigation, and closure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 22852, ensure that the procedure meets the criteria for removal of a previously implanted segmental spinal instrumentation device. It is important to follow the specific guidelines provided by the payer regarding modifiers and documentation requirements. Modifier 78 may be used if the patient needs to return to the operating room for a related procedure during the postoperative period.

8. Historical information

CPT 22852 was added to the Current Procedural Terminology system on January 1, 1990. There have been several updates to the code, including being added and removed from the Inpatient Only (IPO) list by Medicare.

9. Examples

1. A patient with a previously implanted segmental spinal instrumentation device undergoes removal due to infection.
2. A patient experiences severe pain and requires the removal of a segmental spinal instrumentation device.
3. A patient’s body rejects the previously implanted segmental spinal instrumentation device, necessitating its removal.
4. A segmental spinal instrumentation device fails, and the provider performs a removal procedure.
5. A patient requires the removal of a segmental spinal instrumentation device due to a combination of infection and pain.
6. A previously implanted segmental spinal instrumentation device is removed from a patient who experienced failure of the device.
7. A patient undergoes removal of a segmental spinal instrumentation device due to infection and rejection.
8. A provider performs a removal procedure on a patient who experienced pain and failure of the segmental spinal instrumentation device.
9. A patient’s body rejects the previously implanted segmental spinal instrumentation device, resulting in the need for removal.
10. A segmental spinal instrumentation device is removed from a patient due to infection and failure.