Overview of CPT Code 22836: Posterior spinal fusion, posterior approach, single level

Overview of CPT Code 22836: Posterior spinal fusion, posterior approach, single level

CPT Code 22836 refers to a surgical procedure known as posterior spinal fusion, which is performed through the back to stabilize the spine at a single level. This procedure is typically indicated for patients with spinal instability or deformities.

When CPT Code 22836 is Used?

This procedure is appropriate in various clinical scenarios.

• Severe spinal instability due to trauma or degenerative disease.
• Spondylolisthesis where one vertebra slips over another.
• Spinal deformities such as scoliosis.
• Failed conservative treatment for back pain or instability.

Symptoms Indicating This Procedure

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

• Chronic back pain that does not improve with conservative treatment.
• Numbness or weakness in the legs.
• Difficulty walking or maintaining balance.
• Visible spinal deformity.

Causes and Risk Factors

Several factors can contribute to the need for this procedure.

• Degenerative disc disease.
• Traumatic injury to the spine.
• Genetic predisposition to spinal disorders.
• 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 the bony structures.
• Electromyography (EMG) to evaluate nerve function.

Procedure Description

The procedure involves several key steps.

• Patient is placed under general anesthesia.
• An incision is made along the midline of the back.
• Muscle and tissue are carefully moved aside to access the spine.
• The affected vertebrae are prepared for fusion by removing any damaged disc material.
• Bone graft material is placed between the vertebrae to promote fusion.
• Instrumentation such as rods and screws may be used to stabilize the spine.
• The incision is closed with sutures or staples.

Preparation for the Procedure

Patients should follow specific guidelines before surgery.

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

Recovery and Aftercare

Recovery can vary, but certain aspects are common.

• 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.
• Wound care instructions to prevent infection.

Possible Complications

As with any surgery, there are potential risks.

• Infection at the surgical site.
• Nerve damage leading to weakness or numbness.
• Non-union of the vertebrae, requiring further surgery.
• Blood clots in the legs or lungs.

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Post-Procedure Follow-Up

Follow-up care is essential 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.
• Long-term follow-up may be necessary for ongoing evaluation.

Alternative Treatments

There are non-surgical options available.

• 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 to aid their recovery at home.

• Follow all post-operative care instructions from the surgeon.
• Keep the surgical site clean and dry.
• Avoid heavy lifting and strenuous activities.
• Engage in light walking to promote circulation.

Patient Education & Prevention

Education is key to preventing future issues.

• Maintain a healthy weight to reduce spinal stress.
• Practice good posture to support spinal health.
• Engage in regular exercise to strengthen back muscles.
• Avoid smoking, as it can impede healing.

Billing and Coding Information

CPT Code: 22836

Category: Surgery

Common Modifiers:

• 50 - Bilateral procedure
• 59 - Distinct procedural service

Average Cost and Insurance Coverage

Costs can vary based on several factors.

• Average cost ranges from $30,000 to $60,000.
• Insurance typically covers the procedure if deemed medically necessary.
• Out-of-pocket costs depend on the patient's insurance plan.

Related CPT Codes

• 22630 - Posterior Lumbar Interbody Fusion
• 22632 - Spinal Fusion, Posterior or Lateral Approach, Single Level
• 22830 - Posterior spinal fusion, posterior approach
• 22840 - Posterior spinal fusion, posterior approach, single level
• 22851 - Insertion of intervertebral biomechanical device