Clinical Context
A 54-year-old patient with a history of prior cervical total disc replacement presents with progressive neck pain, radiculopathy, and radiographic evidence of prosthesis failure and device loosening at two contiguous cervical levels. After multidisciplinary evaluation including neurosurgery or orthopedic spine surgery, the operative plan is removal of the failed cervical artificial disc at one interspace with simultaneous removal of a second artificial disc at an adjacent cervical interspace during the same anesthetic session. The procedure is performed in an operating room, typically at a hospital inpatient or ambulatory surgery center, under general endotracheal anesthesia. Preoperative workflow includes imaging review (plain radiographs and CT/MRI as indicated), informed consent discussing risks of explantation and possible fusion, anesthesia evaluation, and documentation of prior implant details. Intraoperative steps include exposure of the cervical interspaces, careful explantation of the initial prosthesis, removal of the additional prosthesis at the second interspace (reported as add‑on procedure 0095T), hemostasis, and either revision reconstruction (such as fusion or replacement) or staged closure depending on intraoperative findings. Postoperative workflow includes recovery in PACU, neurologic monitoring, pain control, discharge planning (same‑day discharge or inpatient admission based on clinical status), and detailed operative and implant removal reports for coding and billing reconciliation.
Coding Specifications
| Modifier | Description | When to Use |
|---|
00 | Modifier not otherwise specified (placeholder) | Rarely used; include only if required by payer-specific rules |
| 22 | Increased procedural services | Use when work, time, or complexity of the procedure is substantially greater than typical and well documented (e.g., significant adhesions or unexpected complexity during explantation). |
| 23 | Unusual anesthesia — procedure normally done with local/ MAC but performed under general due to medical condition | Use when general anesthesia is required for unusual circumstances and documentation supports the reason. |
| 26 | Professional component | Use when reporting only the physician's professional service separate from technical components of imaging or monitoring billed by facility. |
| 50 | Bilateral procedure | Use when a bilateral cervical approach would be applicable; rarely used for midline cervical disc removals but included if payer requires. |
| 52 | Reduced services | Use when the procedure is partially reduced or not completed as intended and documentation supports reduced service. |
| 53 | Discontinued procedure | Use when the procedure is started but discontinued due to extenuating circumstances; documentation must justify cessation. |
| 62 | Two surgeons | Use when two surgeons from different specialties perform distinct portions of the procedure simultaneously and documentation supports co-surgery. |
| 66 | Surgical team (multiple surgeons) | Use when a surgical team approach is required and defined by institutional policy; apply per payer rules. |
| 78 | Return to the operating room for a related procedure during the postoperative period | Use when the patient returns to the OR for a related complication or revision within the global period. |
| 80 | Assistant surgeon | Use when an assistant surgeon performs a portion of the procedure and documentation supports assistant involvement. |
| 81 | Minimum assistant surgeon | Use when an assistant surgeon's role meets criteria for minimum assistance per payer policies. |
| 82 | Assistant surgeon when qualified resident surgeon not available | Use when no qualified resident is available and an assistant surgeon is used; documentation required. |
| AD | Medical supervision by the same physician of more than four concurrent anesthesia procedures | Use if the operating physician provides supervision as defined by anesthesia billing rules. |
| Taxonomy Code | Specialty | Notes |
|---|
208000000X | Orthopaedic Surgery | Orthopedic spine surgeons commonly perform cervical artificial disc explantation and revision. |
208600000X | Neurological Surgery | Neurosurgeons frequently manage cervical disc prosthesis removal and complex cervical revision cases. |
207XS0102X | Spine Surgery (Orthopedic) | Spine-focused orthopedic surgeons with specific spine subspecialty practice. |
208200000X | Orthopedic Surgery of the Spine | Providers focused on spine procedures and revisions. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
M50.20 | Other cervical disc displacement, unspecified cervical region | Cervical disc displacement can cause prosthesis failure or recurrent radiculopathy prompting removal. |
| M50.30 | Other cervical disc degeneration, unspecified cervical region | Degenerative changes adjacent to or underlying a disc prosthesis may necessitate explantation and revision. |
| M50.10 | Cervical disc disorder with radiculopathy, unspecified cervical region | Radiculopathy from prosthesis malfunction or adjacent segment disease is a common indication for removal. |
| T85.31XA | Breakdown (mechanical) of artificial cervical disc, initial encounter | Specific code used for mechanical failure of an implanted cervical artificial disc requiring removal. |
| T84.040A | Displacement of internal prosthetic joint device, initial encounter | Applicable when prosthetic displacement or migration prompts explantation; used when coding conventions direct. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
0095T | Removal of additional artificial disc in another cervical interspace at the same operative session as an initial cervical artificial disc removal (add-on) | This is the add-on code describing removal of the second cervical artificial disc during the same session; reported in addition to the primary cervical artificial disc removal code. |
| 22899 | Unlisted procedure, spine | Used if a specific revision or reconstruction procedure performed after explantation does not have a precise CPT code; requires operative report submission and payer review. |
| 22551 | Arthrodesis, anterior, for cervical spine, single level; includes discectomy and decompression | Commonly reported when prosthesis removal is followed by anterior cervical fusion at the same level as revision. |
| 22845 | Anterior instrumentation; 2 to 3 vertebral segments | Reported when anterior plate fixation is placed during reconstruction after disc explantation. |
| 20680 | Removal of implanted foreign body, deep (e.g., exploration of spine implant) | May be reported for removal of deep hardware if coding guidance indicates separate reporting beyond the add-on disc removal code. |
| 0094T | Removal of initial cervical artificial disc prosthesis (primary) | The primary code describing removal of the initial cervical artificial disc; 0095T is reported as an add-on for the additional interspace removal. |