July 8, 2021

Question:
The provider listed one of the procedure statements as bilateral percutaneous L4-L5 segmental instrumentation placement along with the fusion and decompression procedures. In the body of the note he describes placing instrumentation on both sides for the L4-L5. We queried the provider asking for correction of listed procedure to non-segmental (22840).  The provider replied that per his note he did both sides, the right and left and therefore he believes it is segmental.  Do we have the correct interpretation on this?

Answer:
This is a good example of where CPT language and doctor language aren’t the same.  Don’t get hung up on the words “non-segmental” or “segmental.”  Just count the number of attachments points on the spine to code correctly.  Your example is correctly coded using 22840 because there are only two points of attachment on the spine, L4 and L5.

*This response is based on the best information available as of 7/8/21.