2025 CPT code 22855
(Active) Effective Date: N/A Surgery - Musculoskeletal System Feed
Removal of anterior spinal instrumentation.
Modifiers such as 22 (Increased Procedural Services), 50 (Bilateral Procedure), 51 (Multiple Procedures), 78 (Return to the Operating Room), may be applicable in specific circumstances.
Medical necessity must be established for the removal of anterior spinal instrumentation. This involves demonstrating that the hardware is causing complications (e.g., pain, infection, hardware failure), or that its removal is a necessary step in a planned treatment course (e.g., removal of temporary stabilization hardware after fracture healing).
The surgeon prepares the patient and administers anesthesia. A longitudinal incision is made in the abdomen or chest. Surrounding muscles and tissues are retracted to expose the instrumentation. Screws and other fixation devices are removed. The area is irrigated, bleeding is controlled, and the incision is closed.
In simple words: The surgeon removes metal hardware, such as screws and rods, that were previously placed in the front of your spine during a prior surgery. This is often done if the hardware is causing problems like pain or infection, or if it's no longer needed.
This code describes the surgical removal of previously implanted spinal instrumentation from the anterior (front) aspect of the spine.This includes the removal of any hardware like screws, rods, plates, or other fixation devices.
Example 1: A patient experiences persistent pain after anterior spinal fusion surgery, and the implanted hardware is determined to be the cause. The surgeon removes the anterior instrumentation., A patient develops an infection around the site of anterior spinal instrumentation. The surgeon removes the hardware to address the infection., A patient with a spinal fracture has anterior instrumentation placed for temporary stabilization. Once the fracture heals, the surgeon removes the hardware.
Documentation should include the reason for removal, type of instrumentation removed, operative report detailing the procedure, and any complications encountered. Evidence of prior spinal surgery with anterior instrumentation placement is crucial.
- Payment Status: Active
- Specialties:Orthopedic Surgery, Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center