Overview of CPT Code 22842: Posterior spinal fusion, additional level

Overview of CPT Code 22842: Posterior spinal fusion, additional level

CPT Code 22842 refers to the surgical procedure of posterior spinal fusion at an additional level, typically performed to stabilize the spine and alleviate pain caused by spinal instability or deformity.

When CPT Code 22842 is Used?

This procedure is indicated in various clinical scenarios.

• Recurrent back pain due to spinal instability.
• Scoliosis or other spinal deformities requiring correction.
• Post-traumatic spinal instability following an injury.
• Degenerative disc disease with associated instability.

Symptoms Indicating This Procedure

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

• Chronic back pain that does not respond to conservative treatments.
• Numbness or weakness in the legs.
• Difficulty walking or maintaining balance.
• Visible spinal deformity or abnormal curvature.

Causes and Risk Factors

Several factors can contribute to the need for this procedure.

• Trauma or injury to the spine.
• Genetic predisposition to spinal disorders.
• Degenerative diseases such as arthritis.
• Previous spinal surgeries that may 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.

• Administer anesthesia to ensure patient comfort.
• Make an incision along the back to access the spine.
• Remove any damaged or diseased tissue as necessary.
• Insert bone graft material to promote fusion between vertebrae.
• Use hardware such as rods and screws to stabilize the spine.
• Close the incision 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, including over-the-counter drugs.
• Arrange for transportation to and from the hospital.
• Follow any specific instructions provided by the healthcare team.

Recovery and Aftercare

Post-operative recovery is crucial for successful outcomes.

• Stay in the hospital for monitoring for 1-3 days post-surgery.
• Gradually increase activity levels as advised by the surgeon.
• Follow a prescribed pain management plan.
• Attend physical therapy sessions to aid recovery.

Possible Complications

As with any surgery, 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

Regular follow-up is essential for monitoring recovery.

• Initial follow-up appointment within 2 weeks post-surgery.
• Subsequent visits at 6 weeks, 3 months, and 6 months.
• Regular imaging studies to assess spinal fusion progress.

Alternative Treatments

There are non-surgical options available for managing symptoms.

• Physical therapy to strengthen back muscles.
• Chiropractic care for spinal alignment.
• Pain management techniques including medications.
• Epidural steroid injections to reduce inflammation.

Home Care Tips

Patients can take steps at home to aid recovery.

• Keep the surgical site clean and dry.
• Avoid heavy lifting and strenuous activities.
• Use ice packs to reduce swelling and discomfort.
• Follow the prescribed medication regimen.

Patient Education & Prevention

Understanding the condition can help prevent recurrence.

• Maintain a healthy weight to reduce spinal stress.
• Engage in regular low-impact exercise.
• Practice good posture to support spinal health.
• Avoid smoking, which can impede healing.

Billing and Coding Information

CPT Code: 22842

Category: Surgery

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 $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

• 22840 - Posterior spinal fusion, posterior approach, single level
• 22630 - Posterior Lumbar Interbody Fusion
• 22633 - Spinal Fusion, Posterior Interbody
• 22841 - Posterior spinal fusion, each additional segment
• 22612 - Spinal Fusion, Posterior or Lateral Approach, Single Level