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2025 CPT code 22865

Removal of a single artificial disc in the lumbar spine, anterior approach.

Follow all CPT coding guidelines and payer-specific requirements. Accurate coding necessitates detailed documentation of the procedure performed, including approach, level(s), and any complications encountered.

Modifiers may be applicable depending on the circumstances of the procedure (e.g., modifier 51 for multiple procedures, modifier 62 for two surgeons).Consult the CPT manual and payer guidelines for appropriate modifier use.

Medical necessity is established through documentation of persistent pain, neurological symptoms, instability, infection, or failure of the previous artificial disc replacement, unresponsive to conservative management.The procedure must be deemed medically necessary by the treating physician and supported by sufficient clinical evidence.

The surgeon's responsibilities include pre-operative planning, obtaining informed consent, performing the surgical procedure (including meticulous dissection, removal of the artificial disc, hemostasis, and closure), post-operative care, and follow up.

IMPORTANT:Do not report 22865 in conjunction with 49010. For additional interspace, see Category III code 0164T. Codes 22856-22865 include fluoroscopy when performed. For decompression, see 63001-63048.

In simple words: The doctor removes an artificial disc (a man-made replacement for a damaged disc) from the lower back through an incision in the front of the body. This is done to address problems caused by a previous artificial disc replacement.

Removal of total disc arthroplasty (artificial disc), anterior approach, lumbar spine, single interspace.This procedure involves the surgical removal of a previously implanted artificial disc in the lower back via an anterior approach.The surgeon will reopen the previous incision, carefully mobilize surrounding structures (muscles, vessels, ureter), remove the artificial disc using instruments like rongeurs and curettes, irrigate the area, control bleeding, and close the incision in layers.

Example 1: A 60-year-old female patient with persistent back pain and radiculopathy following a previous anterior lumbar interbody fusion (ALIF) with artificial disc replacement at L4-L5. The artificial disc has failed, and the patient is scheduled for removal of the device and possible fusion., A 55-year-old male patient experiencing recurrent back pain and instability after a total disc arthroplasty at L3-L4.The patient undergoes removal of the failed implant to alleviate pain and prepare for revision surgery., A 70-year-old patient with infection at the site of a previously implanted artificial disc. Removal of the infected device is necessary to treat the infection and prevent its spread.

Preoperative imaging (MRI, CT), operative report detailing the surgical technique, removal of the artificial disc, and closure; postoperative imaging as needed; pathology report if tissue is sent for analysis; detailed documentation of patient's symptoms, response to treatment and follow-up care.

** Fluoroscopy is included in codes 22856-22865 when performed.For decompression, refer to codes 63001-63048.

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