Overview of CPT Code 22802:posterior-spinal-fusion-posterior-approach-single-level

Overview of CPT Code 22802:posterior-spinal-fusion-posterior-approach-single-level

CPT Code 22802 refers to a surgical procedure known as posterior spinal fusion, performed through a posterior approach at a single level of the spine. This procedure is typically indicated for patients with spinal instability or deformity, aiming to stabilize the spine and alleviate pain.

When CPT Code 22802 is Used?

This procedure is appropriate in various clinical scenarios.

• Severe spinal instability due to trauma or degenerative disease.
• Spondylolisthesis causing significant pain or neurological symptoms.
• Spinal deformities such as scoliosis that require correction.
• Failed conservative treatment for back pain related to spinal instability.

Symptoms Indicating This Procedure

Patients may report a variety of symptoms that lead to the consideration of this procedure.

• Chronic back pain that does not improve with conservative treatments.
• Radiating pain into the legs or arms.
• Numbness or weakness in the limbs.
• Difficulty walking or maintaining balance.

Causes and Risk Factors

Several factors can contribute to the need for this procedure.

• Degenerative disc disease.
• Traumatic injuries to the spine.
• Congenital spinal deformities.
• Previous spinal surgeries that have failed.

Diagnostic Tests Before Procedure

Several diagnostic tests are typically performed to assess the need for surgery.

• X-rays to evaluate spinal alignment and stability.
• MRI scans to assess soft tissue and nerve involvement.
• CT scans for detailed imaging of bony structures.
• Electromyography (EMG) to evaluate nerve function.

Procedure Description

The procedure involves several key steps to ensure successful spinal fusion.

• Patient is placed under general anesthesia.
• A posterior incision is made over the affected spinal level.
• Muscle and soft tissue are carefully retracted to expose the spine.
• Bone graft material is placed between the vertebrae to promote fusion.
• Instrumentation such as rods and screws may be used for stabilization.
• The incision is closed in layers, and sterile dressings are applied.

Preparation for the Procedure

Patients should follow specific guidelines to prepare for surgery.

• Avoid eating or drinking after midnight before the surgery.
• Discuss all medications with the surgeon, including over-the-counter drugs.
• Arrange for transportation to and from the hospital.
• Follow any pre-operative instructions provided by the healthcare team.

Recovery and Aftercare

Recovery from this procedure typically involves several stages.

• Hospital stay of 1 to 3 days post-surgery.
• Gradual return to normal activities over several weeks.
• Physical therapy may be recommended to aid recovery.
• Pain management with prescribed medications as needed.

Possible Complications

As with any surgical procedure, there are potential risks involved.

• Infection at the surgical site.
• Nerve damage leading to weakness or numbness.
• Non-union of the bone graft.
• Blood clots in the legs or lungs.

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Post-Procedure Follow-Up

Follow-up care is crucial for monitoring recovery.

• Initial follow-up appointment within 2 weeks post-surgery.
• Regular check-ups every 4 to 6 weeks for the first few months.
• Imaging studies may be repeated to assess fusion progress.

Alternative Treatments

There are non-surgical options available for managing spinal issues.

• Physical therapy to strengthen back muscles.
• Chiropractic care for spinal alignment.
• Pain management techniques including injections.
• Medications such as NSAIDs for pain relief.

Home Care Tips

Patients can take steps at home to aid recovery.

• Keep the surgical site clean and dry.
• Follow prescribed medication schedules.
• Engage in light activities as tolerated, avoiding heavy lifting.
• Use ice packs to reduce swelling and discomfort.

Patient Education & Prevention

Understanding the condition can help prevent recurrence.

• Maintain a healthy weight to reduce spinal stress.
• Engage in regular exercise to strengthen back muscles.
• Practice good posture to minimize strain on the spine.
• Avoid high-impact activities that may exacerbate spinal issues.

Billing and Coding Information

CPT Code: 22802

Category: Surgical Procedures

Common Modifiers:

• 50 - Bilateral procedure
• LT - Left side
• RT - Right side

Average Cost and Insurance Coverage

Costs can vary based on several factors.

• Average cost ranges from $20,000 to $50,000.
• Insurance typically covers the procedure if deemed medically necessary.
• Out-of-pocket costs depend on the patient's insurance plan.

Related CPT Codes

• 22612 - Spinal Fusion, Posterior or Lateral Approach, Single Level
• 22630 - Posterior Lumbar Interbody Fusion
• 22800 - Spinal Fusion, Posterior or Lateral Approach
• 22804 - Posterior spinal fusion, posterior approach