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2025 CPT code 22849

Reinsertion of spinal fixation device.

If the reinsertion is performed during the global period of the original surgery, modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) should be appended. Modifier 51 (Multiple Procedures) should be appended if significant other procedures are performed during the same session, and these procedures are not considered components of reinsertion.

Modifiers such as 51, 78, 79 can be appended if applicable.

Medical necessity for this procedure should be supported by documentation of the failure or complication of the initial spinal fixation device and how reinsertion is necessary to maintain spinal stability and alignment, or to prevent further complications.

In simple words: The doctor will reinsert a device used to stabilize your spine. This is done if the original device breaks, moves out of place, or causes other problems. The surgery involves removing the old device and putting a new one in its place.

This procedure involves the reinsertion of a spinal fixation device. This surgery is performed to replace a failed device to one or more back bones. It includes the removal of the old hardware and placement of new hardware at the same level(s) without extension of the construct.

Example 1: A patient's spinal fixation device fails due to metal fatigue, requiring reinsertion of a new device., A patient experiences migration of a previously placed spinal fixation device, necessitating removal and reinsertion of the device., A patient develops an infection around their spinal instrumentation, requiring removal of the infected instrumentation and subsequent reinsertion of a new device after the infection clears.

Documentation should include details about the original spinal fixation device, the reason for reinsertion, the type of new device used, operative details, and any associated procedures performed. Evidence of device failure, migration, or other complications should also be documented.

  • Specialties:Orthopedic Surgery, Neurosurgery
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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