2025 CPT code 22216
(Active) Effective Date: N/A Revision Date: N/A Surgery - Spine Surgery Musculoskeletal System Feed
Osteotomy of spine, posterior or posterolateral approach, each additional vertebral segment after the first.
Modifiers 51 (multiple procedures) and 62 (two surgeons) may apply depending on the specific circumstances of the surgical procedure.Modifier 51 is used when this add-on is used in conjunction with an initial osteotomy. Modifier 62 applies only when two surgeons perform distinct parts of the osteotomy.
The medical necessity for a posterior or posterolateral spinal osteotomy is determined by the presence of a significant spinal deformity, impacting function and quality of life.Documentation should support the severity of the deformity, failed conservative management, and the expected improvement in spinal alignment and patient function after the procedure.
The surgeon's responsibilities include pre-operative planning, precise surgical technique to achieve spinal alignment correction, and post-operative care and follow-up.This code focuses on the surgical portion addressing additional vertebral segments beyond the initial osteotomy.The surgeon's detailed knowledge of spinal anatomy and surgical procedures is essential.
In simple words: This code is for extra work done on your spine during a specific type of surgery. If the surgeon cuts into more than one bone in your back during the surgery to correct a curve, this code might be used for the extra bones worked on.It only applies if there was an initial osteotomy already coded.
This CPT code, 22216, represents an add-on code for each additional vertebral segment addressed during a posterior or posterolateral spinal osteotomy, following the initial osteotomy of one vertebral segment (coded separately using codes 22210-22214).The procedure involves incising a vertebra to remove portions of bone, altering spinal column alignment to correct abnormal curvature.This code is only reported in addition to the primary procedure code for the first vertebral segment.It includes the removal of the spinous process, lamina, facets, pedicles, and lateral bone to protect nerve roots and the spinal cord. The procedure also encompasses undercutting the laminar surfaces above and below to safeguard the spinal cord, and final alignment and wound closure.
Example 1: A patient presents with scoliosis (lateral curvature of the spine).The surgeon performs a posterior spinal osteotomy, addressing three vertebral segments.Code 22212 (or 22214, depending on location) would be used for the primary osteotomy, and two units of 22216 would be added for the two additional segments., A patient with a complex spinal deformity requires a posterior osteotomy to correct the curvature.The surgeon finds it necessary to address four vertebral segments. Code 22214 would be billed for the initial segment, and 22216 would be billed three times for the three additional segments., A patient with a burst fracture requires posterior spinal osteotomy and fusion. Two surgeons work together. Surgeon A performs the initial osteotomy and Surgeon B performs the additional segment osteotomy. Both surgeons use modifier 62.Surgeon A reports their work with 22214 and Surgeon B would use 22216.
Detailed operative report specifying the number of vertebral segments addressed, the surgical approach (posterior or posterolateral), and precise description of the osteotomy technique for each segment.Preoperative imaging (X-rays, CT scans), intraoperative images and postoperative imaging to assess surgical correction, and any complications should also be documented.
** This code is specifically for additional vertebral segments addressed during a posterior or posterolateral spinal osteotomy; it does not encompass other spinal procedures.Careful documentation is crucial for accurate coding and reimbursement.
- Global Days: Add-on code; no global period applies. This code is reported in addition to the primary procedure code for the initial osteotomy.
- Payment Status: Active
- Modifier TC rule: Not applicable. This is an add-on code, and no technical component modifier is used.
- Specialties:Orthopedic Surgery, Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center