2025 CPT code 22842
(Active) Effective Date: N/A Surgery - Musculoskeletal System Feed
Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires) for 3 to 6 vertebral segments.
Modifiers like 51 (Multiple Procedures) or 22 (Increased Procedural Services) could be applied if appropriate.
Medical necessity must be established for the primary procedure with which this code is used. The use of instrumentation itself should be justified as necessary for stability, correction of deformity, or as part of the surgical plan for the underlying condition.
The surgeon exposes the posterior spine, prepares the bony structures, and inserts the instrumentation under fluoroscopic guidance. They ensure proper alignment and stability before continuing with the primary procedure.
In simple words: This procedure involves placing fixation devices like rods and screws along the back of the spine across 3 to 6 vertebrae to stabilize it, often during a spinal fusion.
Insertion of posterior segmental spinal instrumentation, such as pedicle screws, dual rods, multiple hooks, and sublaminar wires, spanning 3 to 6 vertebral segments.This code is reported in addition to the primary procedure (e.g., spinal fusion).
Example 1: A patient with spondylolisthesis at L4-S1 undergoes posterior spinal fusion with segmental pedicle screw instrumentation at L4-S1., A patient with scoliosis undergoes posterior spinal fusion from T4-T10. Posterior segmental instrumentation is placed from T4-T10., A patient with a traumatic fracture at L1-L2 undergoes posterior spinal fusion with segmental pedicle screw instrumentation at L1-L3.
Operative report should clearly document the type and location of instrumentation (pedicle fixation, hooks, wires, etc.), the specific vertebral segments involved (e.g., L4-S1), the diagnosis necessitating the instrumentation, and the primary procedure performed.
** Although CPT guidelines define instrumentation by vertebral segment, primary procedures are often defined by vertebral interspace. Ensure accurate counting and documentation to avoid confusion. If documentation is unclear, query the surgeon for clarification.
- Payment Status: Active
- Modifier TC rule: No TC modifier applies to this code.
- Specialties:Orthopedic Surgery, Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center