2025 CPT code 22852
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Spine (Vertebral Column) - Musculoskeletal System Surgery Feed
Removal of posterior segmental spinal instrumentation.
Modifiers may be applicable.For example, 51 (Multiple Procedures), 78 (Unplanned Return to the Operating/Procedure Room), and others depending on the clinical scenario.
Medical necessity for removal must be established through documentation of a specific indication, such as infection, persistent pain, hardware failure, or completion of fracture healing.
The surgeon makes an incision along the patient's back to expose the spinal instrumentation. The various components, such as screws, rods, and plates, are carefully detached from the vertebrae and removed.The surgical site is then irrigated and closed.
In simple words: The surgeon removes metal implants like rods, screws, and plates that were previously attached to the back of your spine to stabilize it. This might be done because the implants are no longer needed, are causing problems, or have broken.
This code describes the removal of previously placed spinal instrumentation from the posterior (back) segments of the spine.Segmental instrumentation refers to fixation devices attached to at least three vertebral segments. This procedure often involves the removal of rods, screws, plates, and other hardware.
Example 1: A patient experiences persistent pain and infection after spinal fusion surgery with posterior segmental instrumentation. The surgeon removes the instrumentation., A patient with a healed spinal fracture initially treated with posterior segmental instrumentation now requires removal of the hardware., A patient's posterior spinal instrumentation fails due to a device malfunction, requiring its removal.
Operative report detailing the reason for removal, the specific instruments removed, the levels of the spine involved, and any complications encountered. Preoperative imaging studies supporting the need for removal. Documentation of infection, hardware failure, or pain if those are the reasons for removal.
- Revenue Code: P3D
- Payment Status: Active
- Specialties:Orthopedic Surgery, Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center