CurrentSelectHealthPolicy # 21

Exploration of spinal fusion (CPT 22830) billing/coverage

Defines SelectHealth's coverage and billing stance for reporting CPT 22830 (exploration of spinal fusion) when performed with other spinal fusion procedures across Commercial, Medicare (Select Health Advantage), and Medicaid/CHIP (Select Health Community Care) plans.

Policy Summary

PayerSelectHealth

PolicyExploration of spinal fusion (CPT 22830) billing/coverage

Policy CodePolicy Policy # 21

Change TypeNo material changes

Effective DateSep 1, 2005

Next Review Date

Key ActionDo not separately report CPT 22830 when performed during a more major spinal fusion in the same anatomic area; report CPT 22830 with modifier 59 only when the exploration is in a different anatomic area.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

22830Primary code referenced

IncludedExploration considered inclusive when performed with more major spinal fusion procedure

59 allowedModifier 59 may permit separate reporting only when exploration is in a different anatomic area

Policy Snapshot

This policy is CURRENT and defines SelectHealth's coverage and billing stance for reporting CPT 22830 (Exploration of spinal fusion) when performed with other spinal fusion procedures across SelectHealth Commercial, SelectHealth Advantage (Medicare/CMS), and SelectHealth Community Care (Medicaid/CHIP) plans. The policy status is CURRENT and the subject is Exploration of spinal fusion (CPT 22830) billing/coverage (Policy # 21; Implementation Date: 9/1/05).

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When CPT 22830 May Be Reported Separately

When CPT 22830 may be reported separately

Conditions under which exploration of a spinal fusion (CPT 22830) may be separately reported:

ANY of the following

Exploration is performed in a different anatomic area than another spinal procedure; in that case CPT 22830 may be reported with modifier 59.

ALL of the following

If exploration is routine during performance of a spinal fusion at an adjacent site, it is considered included in the more major spinal fusion procedure and should not be reported separately.
Once bone and instrumentation have been removed and a new fusion is performed, the procedure is considered a major spinal fusion (not an exploration) and CPT 22830 should not be reported.

Billing Rules & Documentation Notes

Billing Rule

Do not separately report CPT 22830 with other spinal procedures in same anatomic area

CPT 22830 (exploration of spinal fusion) is considered included when performed during a more major spinal fusion procedure in the same anatomic area and should not be reported separately.

22830

Billing Rule

Use modifier 59 only when exploration is in different anatomic area

If the exploration of a previous fusion is performed in a different anatomic area than another spinal procedure, CPT 22830 may be reported separately with modifier 59 per National Correct Coding Initiative guidance.

22830
Modifier 59

Clinical / Administrative Context

Exploration of a prior spinal fusion is a procedure to assess the fusion site and is typically considered part of the larger spinal fusion or hardware removal procedure; therefore, it is generally included and should not be reported separately when performed in the same anatomic area. SelectHealth’s Commercial, Medicare (Select Health Advantage), and Medicaid/CHIP (Select Health Community Care) policies follow this approach and will consider CPT 22830 included in the more major fusion procedure unless the exploration meets the limited criteria for separate reporting with modifier 59.

Per the policy and supporting sources, if bone and instrumentation have been removed and a new fusion is performed, the work is classified as a major spinal fusion (not an exploration) and CPT 22830 should not be reported separately. The policy references CPT code 22830 as “Exploration of spinal fusion.”

Definitions

Exploration of spinal fusion (CPT 22830)Procedure to explore a prior spinal fusion site to determine stability; considered a routine part of performing spinal fusion and therefore often included in the primary fusion procedure unless performed in a different anatomic area or when prior instrumentation/bone have been removed and a new fusion is performed.

Policy Summary

PayerSelectHealth

PolicyExploration of spinal fusion (CPT 22830) billing/coverage

Policy CodePolicy Policy # 21

Change TypeNo material changes

Effective DateSep 1, 2005

Next Review Date

SourceLink

On This Page

OpenPayer

Exploration of spinal fusion (CPT 22830) billing/coverage

Policy Snapshot

When CPT 22830 May Be Reported Separately

Codes and Billing Categories

Billing Rules & Documentation Notes

Clinical / Administrative Context

Exploration of spinal fusion (CPT 22830) billing/coverage

Policy Snapshot

When CPT 22830 May Be Reported Separately

Codes and Billing Categories

Billing Rules & Documentation Notes

Clinical / Administrative Context

Additional Policies to Review