Basics of Lateral Extracavitary Approach (LECA) Spinal exam

The lateral extracavitary approach (LECA) requires resection of the ribs, pleura and/or peritoneum and dissection of spinal/paraspinal tissues to access the vertebral bodies/disc. The advantage of this technique is that it provides the surgeon with access to both the posterior and lateral aspects of the spinal canal through the same incision. Documentation of manipulation of the pleura and/or peritoneum is the clue that a LECA was used.

Medical terms used in coding LECA spinal exams:

Arthrodesis: Surgical fixation or fusion of a joint to reduce pain and improve stability, performed openly or arthroscopically
Decompression: Release of pressure
Discectomy: Surgical excision of an intervertebral disk
Interspace: Space between two similar objects
Transverse: Crosswise at right angles to the long axis of a structure or par

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Coding tips for CPT code 22532, 22533 and 22534

Arthrodesis is performed by lateral extracavitary approach. A midline incision is made in the area of the fractured segment and inferiorly curved out to the lateral plane. The paraspinous muscles are exposed, lifted off the spinous processes, and divided and lifted off the ribs. Imaging must be used to identify the targeted interspace. The corresponding rib is dissected from the intercostal muscles and resected in one piece from the curve to the costovertebral connection. The appropriate transverse process and part of the facet and pedicle are removed with a drill from the lateral aspect. The dura and the vertebral body are exposed from the dorsolateral view.

Further posterior and lateral access to the vertebral body is gained by gently retracting the nerve root and surrounding structures. A minimal discectomy is now done to prepare the interspace by removing the damaged tissue with curettes and rongeurs. Cartilage is scraped, bone is decorticated, and the arthrodesis is accomplished by tapping bone graft material into the vertebral endplates. A drain is placed and closure is done in layers. CPT code 22532 is reported for thoracic arthrodesis; code 22533 is reported for lumbar arthrodesis; and code 22534 for each additional thoracic or lumbar vertebral segment done by lateral extracavitary approach.

22532 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic
22533                                   lumbar
22534                                   thoracic or lumbar, each additional vertebral segment

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Coding guide for CPT code 63101, 63102 and 63103

A vertebral corpectomy with correction of spinal cord or nerve root compression is done for fractures or tumors of the vertebrae. The body of the vertebra may be partially or completely resected. The lateral extracavitary approach is done with a midline incision made in the area of the fractured segment and inferiorly curved out to the lateral plane. The paraspinous muscles are exposed, lifted off the spinous processes, and divided and lifted off the ribs. The targeted vertebral body is identified. The corresponding ribs are dissected from the intercostal muscles and the pleura and resected in one piece from the posterior curve to the costovertebral connection. The appropriate transverse process and part of the facet and pedicle are removed with a drill from the lateral aspect. The dura and the vertebral body are now exposed from the dorsolateral view.

Further posterior and lateral access to the vertebral body is gained by gently retracting the nerve root and surrounding structures. The central portion of the vertebral body is removed with a drill, exposing more area, and any bone fragments or tumor masses are removed away from the spinal cord or nerve roots. Curettes and rongeurs are used to remove disc material. At this point, any necessary fusion, intervertebral reconstruction, or grafting is undertaken and reported separately. Cartilage is scraped, bone is decorticated, and an arthrodesis or reconstruction is accomplished by tapping bone graft material into the vertebral endplates. A drain is placed and closure is done in layers. CPT code 63101 is reported for vertebral corpectomy by lateral extracavitary approach on a single thoracic segment, code 63102 for a single lumbar segment, and code 63103 for each additional thoracic or lumbar segment.

63101 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg., for tumor or retropulsed bone fragments); thoracic, single segment
63102                 lumbar, single segment
63103                 thoracic or lumbar, each additional segment

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Do and Don’t Coding tips

Add-on” code, 22534 and 63103 is not subject to multiple procedure rules. No reimbursement reduction or modifier 51 is  applied. Add-on codes describe additional intra-service work associated with the primary procedure. They are performed  by the same physician on the same date of service as the primary service/procedure, and must never be reported as a  stand-alone code.

Arthrodesis is frequently performed with other procedures on the spine, which should be reported separately.

If spinal instrumentation is performed, it is listed separately using CPT code 22840–22847.

Any bone graft is also reported separately should be reported with CPT code 20930–20938.

Any vertebral corpectomy, bone graft, arthrodesis, or spinal instrumentation is reported separately.

By definition, a fusion of one level involves 2 vertebrae; a fusion of two levels involves 3 vertebrae, etc. For example, a surgeon may document fusion of L3-L5. This involves 2 levels (L3-L4 and L4-L5) and 3 vertebrae (L3, L4, and L5); reported with CPT codes 22533 and 22534.

As with any procedure, it is important to read the dictated operative report to capture all parts of the procedure. Codes 22532-22534 include a minimal diskectomy to prepare the interspace (part of the surgical approach). However, diskectomy performed for spinal cord decompression is reported with codes 63101-63103.

Bone graft procedures are separately reported using the appropriate bone graft codes 20930-20938.

Vertebral corpectomy procedures are separately reported with codes 63101-63103 and spinal instrumentation procedures are separately reported with codes 22840-22855

Reference:

CPT Asst March 17 – Spinal Biomechanical Devices
CPT Asst Feb 17 – Reporting Insertion of Spinal Dev.
CPT Asst July 13 – Spinal Instrumentation
CPT Asst April 12 – Spine Bone Graft (Codes 20930-20938)
CPT Asst Oct 09 – Lateral Extracavitary Approaches to Lumbar Spin