How To Use CPT Code 22855

CPT code 22855 describes the removal of anterior instrumentation from 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 22855?

CPT 22855 is used to describe the removal of previously implanted spinal instrumentation from the anterior (front) portion of the spine. This procedure is performed when the instrumentation needs to be removed due to reasons such as infection, pain, rejection, or failure of the device.

2. Official Description

The official description of CPT code 22855 is: ‘Removal of anterior instrumentation.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes a longitudinal incision in the abdomen or chest to access the anterior portion of the spine.
3. The surrounding muscles and tissues are retracted to fully expose the instrumentation.
4. The provider removes the screws and/or other fixation components and detaches the device.
5. The area is irrigated with antibiotics to prevent infection.
6. The provider checks for bleeding, removes any remaining instruments, and closes the incision.

4. Qualifying circumstances

CPT 22855 is performed when there is a need to remove anterior spinal instrumentation due to infection, pain, rejection, or failure of the device. It is important to note that this code should not be reported if the removal is done to explore spinal fusion.

5. When to use CPT code 22855

CPT code 22855 should be used when the provider performs the removal of anterior spinal instrumentation. It is important to ensure that the procedure meets the qualifying circumstances mentioned above.

6. Documentation requirements

To support a claim for CPT 22855, the following documentation should be included:

• Reason for the removal of anterior instrumentation (infection, pain, rejection, or failure)
• Details of the procedure, including the approach used (abdomen or chest)
• Confirmation of the removal of screws and/or other fixation components
• Documentation of irrigation with antibiotics
• Assessment of bleeding and any necessary interventions
• Confirmation of closure of the incision

7. Billing guidelines

When billing for CPT 22855, ensure that the procedure involves the removal of anterior instrumentation. It is important to follow the specific documentation requirements and guidelines provided by the payer. Modifier 59 may be used to indicate that the instrumentation removal was performed at separate anatomic locations.

8. Historical information

CPT 22855 was added to the Current Procedural Terminology system on January 1, 1990. It was initially removed from the Inpatient Only (IPO) list in 2017 but was later added back to the list in 2022.

9. Examples

1. A patient undergoes the removal of anterior instrumentation due to infection in the spine.
2. A patient experiences severe pain after anterior spinal instrumentation and requires the removal of the device.
3. A patient’s body rejects the anterior spinal instrumentation, necessitating its removal.
4. The anterior spinal instrumentation fails to provide the desired outcome, and the provider decides to remove it.
5. A patient requires the removal of anterior instrumentation due to a combination of infection and pain.
6. A patient’s body shows signs of rejecting the anterior spinal instrumentation, leading to its removal.
7. The anterior spinal instrumentation fails to provide the expected stability, and the provider decides to remove it.
8. A patient experiences persistent pain after anterior spinal instrumentation and requires the removal of the device.
9. The anterior spinal instrumentation becomes infected, necessitating its removal.
10. A patient’s body shows signs of rejecting the anterior spinal instrumentation, leading to its removal.