January 22, 2015

Question:
Our surgeon documented a revision of an interbody fusion and wants to report 22849 for the removal of a cage and placement of a new cage. Is this an acceptable use of the re-insertion code?

Answer:
Great question and one that is not uncommonly asked in the Orthopaedic Coding courses presented by Mary LeGrand and Margi Maley. CPT code 22849 is not appropriate to report in this scenario. If the surgeon’s documentation supports a level of complexity over and above for the revision interbody fusion, the possibility of appending modifier 22 for the increased procedural service and complexity exists.