2025 CPT code 22116
(Active) Effective Date: N/A Revision Date: N/A Surgery - Spine Musculoskeletal System Feed
Partial excision of a vertebral body for an intrinsic bony lesion, without spinal cord or nerve root decompression, for each additional vertebral segment.
Modifiers 51 (multiple procedures), 62 (two surgeons), and 76 (repeat procedure) may be applicable depending on the circumstances.
The medical necessity for this procedure is established by the presence of a symptomatic intrinsic bony lesion in the vertebra.The need for partial excision must be documented, demonstrating that less invasive procedures are insufficient.
The surgeon's responsibility includes preparing the patient, making an incision, dissecting to the bone, removing the diseased bone, irrigating, and closing the incision.Additional procedures like bone grafting or instrumentation may be handled by the same or other surgeons.
In simple words: This code describes a surgery where the doctor removes a damaged part of a vertebra (a bone in your neck or back).It's for a problem inside the bone itself, and the doctor doesn't need to relieve pressure on the spinal cord or nerves during this specific part of the operation.This code is used only if more than one vertebra needs this surgery.
This CPT code, 22116, represents the partial excision of a vertebral body to address an intrinsic bony lesion.This procedure is performed without decompression of the spinal cord or nerve roots. The code is an add-on code and should be reported in addition to the primary procedure code (22110, 22112, or 22114) for each additional vertebral segment excised.Complete or near-complete resection necessitates using vertebral corpectomy codes (63081-63091).
Example 1: A patient presents with a burst fracture of L2. The surgeon performs a corpectomy followed by arthrodesis of L1-L3, using anterior instrumentation and a structural allograft. Code 22116 may be used if multiple vertebral segments are involved in the partial excision., A patient with a history of posttraumatic degenerative disc disease undergoes surgical repair. One surgeon performs an anterior exposure, mobilizing great vessels. Another performs anterior discectomy and fusion, potentially requiring 22116 if additional vertebral segments are addressed., In a case of spinal stenosis, a surgeon performs a partial vertebral body excision at multiple levels, requiring use of 22116 for each additional segment following the initial segment's procedure code.
Detailed operative notes describing the extent of the resection, number of vertebral segments involved, and any additional procedures performed.Imaging studies (X-rays, CT scans) showing the lesion and the extent of the excision.Pre- and post-operative clinical assessment documentation.
** Careful documentation is crucial for appropriate coding and reimbursement.Ensure that the clinical documentation supports the medical necessity for this procedure.Understanding the differences between this code and similar codes for complete vertebral body resection and spinal reconstruction is essential.
- Revenue Code: P3D (MAJOR PROCEDURE, ORTHOPEDIC - OTHER)
- RVU: Information not available in provided text.RVUs vary based on geographic location and other factors.
- Global Days: Information not available in provided text. The global period will depend on the specific procedure and payer guidelines.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Information not available in provided text.
- Specialties:Orthopedic Surgery, Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Outpatient Hospital