2025 CPT code 22548
(Active) Effective Date: N/A Revision Date: N/A Surgery - Spine Musculoskeletal System Feed
Anterior transoral or extraoral arthrodesis of clivus-C1-C2, with or without odontoid process excision.
Modifiers 51 (multiple procedures), 59 (distinct procedural service), and 62 (two surgeons) may be applicable depending on the circumstances of the procedure.
The medical necessity for this procedure is based on the presence of significant instability or pathology at the C1-C2 level that causes persistent pain and/or neurological compromise, refractory to conservative management.Documentation should support the diagnosis, failed conservative treatment, and the need for surgical intervention.
The surgeon is responsible for the entire surgical procedure, including incision, exposure, odontoidectomy (if performed), preparation of the joint surfaces for fusion, placement of the bone graft, hemostasis, and closure of the surgical site.Anesthesiologist, if involved, would bill separately.
In simple words: This code describes a spinal fusion surgery in the neck. The surgeon will fuse two bones in the neck (the atlas and axis) together.This may involve removing part of a bone.The surgery uses an incision either through the mouth or the neck.Other procedures such as bone grafting will be billed separately.
This CPT code encompasses the anterior transoral or extraoral approach to perform arthrodesis (spinal fusion) of the clivus-C1-C2 (atlas-axis) joint.The procedure may involve the excision of the odontoid process.The code includes the surgical preparation of the joint for fusion and placement of the bone graft.Bone graft harvest and spinal instrumentation are reported separately.
Example 1: A patient presents with chronic neck pain and instability due to a C1-C2 fracture.Anterior cervical arthrodesis with odontoidectomy is performed to stabilize the spine. Bone graft is harvested from the iliac crest., A patient with rheumatoid arthritis and severe C1-C2 instability undergoes anterior transoral arthrodesis. No odontoidectomy is necessary.Allograft is utilized., A patient with a history of trauma and significant instability at the C1-C2 level undergoes anterior transoral arthrodesis with odontoidectomy, followed by instrumentation for additional stabilization.The surgeon may append modifier 59 to indicate separate procedures.
** This procedure requires specialized surgical skills and expertise.Accurate documentation is essential for proper reimbursement.
- Revenue Code: P3D (MAJOR PROCEDURE, ORTHOPEDIC - OTHER)
- RVU: This information requires access to a current fee schedule and is not available in the provided text.
- Global Days: The global period for this procedure is not specified in the provided text and would need to be determined based on payer specific guidelines and local policies.
- Payment Status: Active
- Modifier TC rule: The TC modifier does not apply to this code.
- Fee Schedule: Historical fee schedule data is not available in the provided information. Consult your local Medicare Carrier or other payer-specific fee schedules.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center