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2025 CPT code 22595

Arthrodesis, posterior technique, atlas-axis (C1-C2)

Bone grafting is reported separately with codes 20930-20938. If instrumentation (e.g., rods, screws, plates) is used for fixation, it is reported separately with codes 22840-22859. Modifier 62 should not be appended to spinal instrumentation codes when used with 22595.

Medical necessity for 22595 is established by documentation demonstrating instability or significant pain at the C1-C2 joint refractory to conservative treatment. Supporting evidence may include imaging studies (X-rays, CT, MRI) showing the underlying pathology and documentation of failed conservative treatment modalities.

The surgeon is responsible for all aspects of the procedure, including patient positioning, incision, bone preparation, graft placement, wound closure, and post-operative care. They must also determine the appropriate type of bone graft and ensure proper immobilization of the fused vertebrae.

In simple words: This is a surgery to permanently join the first two bones in your neck (the atlas and axis) at the back. The surgeon makes an incision in the back of your neck to access the bones. Small chips of bone are used as a graft to help the bones fuse together, which offers pain relief and neck stability.

This procedure involves the permanent fusion of the first two cervical vertebrae (C1-C2), using a posterior approach. The surgeon accesses the back of the neck, prepares the bony surfaces of the atlas and axis, and then uses a bone graft to promote fusion. The bone graft may be autologous (from the patient's own body) or allograft (from a donor). This procedure is often performed to treat instability or pain caused by various conditions affecting the upper cervical spine.

Example 1: A patient with a fracture of the odontoid process (dens) of C2 undergoes posterior C1-C2 fusion to stabilize the joint., A patient with rheumatoid arthritis and severe instability at the atlantoaxial joint undergoes C1-C2 fusion to prevent spinal cord compression., A patient with congenital atlantoaxial instability undergoes posterior C1-C2 fusion to correct the deformity and improve neck stability.

Documentation should include the diagnosis necessitating the procedure (e.g., fracture, instability, arthritis), details of the surgical approach, type of bone graft used, any instrumentation used for fixation, and post-operative instructions. Imaging studies confirming the diagnosis and post-operative fusion are also required.

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