A Closer Look at Biomechanical Cage & Device Coding

Effective January 1, 2017, CPT^® code 22851 was deleted from the CPT code set and replaced by three new codes to report insertion of biomechanical devices:

CPT Code 22853 – Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)

CPT Code 22854 – Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

CPT Code 22859 – Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

These three new codes are a result of the Centers for Medicare and Medicaid Services (CMS) flagging CPT code 22851 on its list of high expenditure procedure codes not reviewed in at least 6 years. The Relative Value Scale Update Committee (RUC) recommended review of the code because of the frequency of use, historical consistent growth of utilization and the fact that the code had not been surveyed since April 1995. The CPT Editorial Panel approved deletion of CPT code 22851 and creation of CPT codes 22853, 22854 and 22859 to report biomechanical device insertion at the October 2015 CPT meeting.

The phrase, “when performed,” in the code descriptors for 22853 and 22854 has caused some confusion. This new family of codes is reported per level and was designed so that each code captures insertion of both devices with integral anterior instrumentation for device anchoring and devices without integral anterior instrumentation for device anchoring, regardless of approach (anterior, posterior, lateral). The difference in the codes lies in the location of the device insertion (i.e. the intervertebral disc space or the vertebral body defect) and whether interbody arthrodesis is being performed: 22853 for disc space defect with fusion, 22854 for vertebral body defect with fusion, and 22859 for disc space or vertebral body defect without fusion.

Because each code can be used to report insertion of devices with integral anterior instrumentation for device anchoring and devices without integral anterior instrumentation for device anchoring, there are cases in which the surgeon inserts a device without integral instrumentation for device anchoring and should appropriately report separate anterior instrumentation, when placed, using CPT codes 22845, 22846 or 22847 in addition to the appropriate biomechanical device code and the primary procedure code. In cases where the surgeon inserts a device with integral instrumentation for device anchoring (i.e. fixation that cannot be independently implanted), CPT codes 22845, 22846 and 22847 should not be reported. The description of intra-service work for 22853, 22854 and 22859 indicates that “additional fixation not integral to the device… should be coded separately.”

In the Fall 2016, the National Correct Coding Initiative (NCCI) released proposed procedure-to-procedure (PTP) coding edits with a proposed effective date of January 1, 2017 bundling 22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)), 22846 (Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)), and 22847 (Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)) with 22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)), 22854 (Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)) and 22859 (Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)) unless a modifier is used.

ISASS led a coalition of specialty societies to dispute these proposed edits and submitted a letter to NCCI on November 11, 2016. In response to our outreach, NCCI responded on December 13, 2016 that CMS retracted its plans to implement coding edits to bundle 22845, 22846 and 22847 with 22859, but would proceed with implementation of coding edits bundling 22845, 22846, and 22847 with 22853 and 22854 effective April 1, 2017.

We again wrote to NCCI and CMS on February 13, 2017 further opposing implementation of these edits and ISASS met with representatives of CMS and NCCI in August 2017. CMS and NCCI responded on November 21, 2017 by clarifying that surgeons may use modifier 59 to report separate anterior instrumentation (22845-22847) unrelated to anchoring the device, with CPT codes 22853 and 22854.

All CPT code descriptors have been taken from Current Procedural Terminology (CPT®) 2017, American Medical Association. All Rights Reserved. CPT is registered trademark of the American Medical Association.

The coding opinions referenced are those of the ISASS Coding & Reimbursement Task Force based on their coding experience and do not constitute legal advice. Every effort is made to ensure the accuracy of information provided, however, these opinions do not replace information contained in public or private payer policies or any published CPT material. The final decision for coding any procedure must be made by the surgeon, considering regulations of insurance carriers and any local, state or federal laws that apply to the surgeon’s practice. ISASS nor any of its officers, directors, agents, employees, committee members or other representatives shall have any responsibility or liability for any claim, including but not limited to any claims for costs, legal fees, Medicare or insurance fraud, arising from the use of these opinions.