The role of the vascular surgeon in anterior retroperitoneal spine exposure: Preservation of open surgical training

Abstract

Advances in spinal instrumentation and the introduction of artificial disc replacement have resulted in an increased need for anterior exposure of the lumbar spine. The authors present their experience in an academic center with both retroperitoneal and transabdominal dissection in preparation for spinal surgery. They conclude that the procedure is an ideal opportunity for surgical residency training with open vascular exposure and vessel repair. They also illustrate that vascular injury during the procedure is not an uncommon event. Vascular surgeons usually provide the anterior exposure and vessel mobilization while an orthopedic surgeon or neurosurgeon instruments the disc space. Anterior spinal exposure, discectomy, and arthrodesis at the lumbar level are reported by CPT code 22558 and by CPT code 22556 at the thoracic level. These descriptions apply only to a single disk interspace and include all aspects of the operation from exposure to vertebral repair. Since each of these surgeons are performing independent and distinct portions of the procedure, the co-surgeon modifier (-62) is generally appropriate on the CPT codes in question. When the claim is submitted to an insurance carrier as co-surgeons, the fee for that claim is increased by 25 percent and then divided in half (ie, 62.5% of the insurance carrier's fee schedule for that CPT code – hence the number 62 as the modifier) and each of the two physicians, provided they have filed appropriately, should be reimbursed. Both doctors are required to dictate an official operative report and are subject to the 90 day postoperative global period. If more than one level requires exposure and treatment, the additional interspaces are each reported with the add-on CPT code 22585 regardless of whether the interspace is in the chest or abdomen. Therefore, three levels of lumbar exposure would allow for three CPT codes ( 22558 with a -62 modifier, 22585 with a -62 modifier, and 22585 with a -62 and a -59 modifier) and since the add-on code is submitted twice, a -59 (separate and distinct service) modifier is also appended to the second code. Total disc arthroplasty using an artificial disc from an anterior approach at the lumbar level requires the CPT code 22857 for the first disc interspace and the Category III CPT code 0163T is appropriate for all additional interspaces. Removal of such a prosthesis using an anterior approach is described by CPT code 22865 for the first lumbar level and by the Category III CPT code 0164T for subsequent levels. No codes exist at this time for thoracic instrumentation with these new prosthetic devices. Rules for co-surgeon billing apply but, unfortunately, the Category III CPT codes are not reportable with a -62 modifier. Some spine surgeons perform their own anterior exposure and only call for vascular surgery consultation if an issue arises. In this example, a vessel such as the left common iliac vein may be injured. When a physician is asked to help with active intra-abdominal bleeding and he/she repairs the affected area directly, CPT code 35221 is reported. If the traumatic repair requires vein graft revascularization, CPT code 35251 is appropriate whereas CPT code 35281 is more fitting with use of a prosthetic graft reconstruction. If the bleeding requires ligation of a major intra-abdominal artery, CPT code 37617 should be submitted instead. The four additional codes listed above all are subject to a 90-day postoperative global period.