Office, Inpatient Consult, and ER
General Tips
Coding Tips
Learning to code the correct way is important to ensure that you are getting reimbursed for services rendered and to avoid getting into legal trouble (Medicare fraud for overbilling, for example). Even if your office does your coding/billing, it is important to understand what is getting billed under you and so that you can make sure all services provided are being captured by your office staff.
Interspace Versus Segment Terminology
A per segment code means that a single vertebra was worked on in some capacity. That includes the lamina, pars, facet, or vertebral body. A segment code does not mean per motion segment. To show you why a segment code does not mean per motion segment, take CPT code 63081. This code is for cervical corpectomy at one segment. If the per segment for motion segment, then every corpectomy would get 2 CPT codes because one is always working across two motion segments when doing a complete corpectomy. Or, take CPT code 22845 as another example. This code is for anterior instrumentation at 2 or 3 vertebral segments. There is no code for 1 vertebral segment if segment implied per motion segment and one was doing a single level ACDF. For a single level ACDF, with a plate that spans from C5-6, you would use CPT code 22845 since you are working on two segments (vertebra).
A per interspace code means work is being done between two segments (vertebra) or within the disc. This code can be interpreted to mean working across one motion segment.
Established Patients
Established patients are patients have seen a provider in the office within the last 3 years. Specifically, an established patient has been billed for an evaluation and management in the last 3 years. If the patient has not been seen in the office or billed for an evaluation and management, then a new patient code can and should be used. As an example, if a patient was seen in the office 4 years ago but a prescription refill was provided to them 2 years ago, a new patient code would be used when they return to the office since an evaluation and management code would not be used for that refill.
Global Period
The global period is a window of time where all professional services rendered to a patient should not be billed. This period includes the day before surgery, the day of surgery, and 90 days after surgery. All professional services rendered during that period should not be billed (except for interpretation of x-rays which should be billed separately). If a second surgery is performed for a complication, such as infection, it should be coded for the procedure performed (for example, CPT code 11044 which is debridement to the level of bone) with a modifier added to that code (in this example, it would be a 78 modifier). An evaluation and management code can be used the day before or the day of surgery if the decision for surgery is made during that encounter. For example, if a patient has an unstable burst fracture and decision is made to perform operative stabilization, an evaluation and management code can be billed for that encounter. The specific code used will depend on whether the patient was seen in the office or hospital and what level of medical decision making or time went into that encounter (the table for outpatient and inpatient evaluation and management can be used to help with that decision).
The global period also applies to non-operative management of fractures if a closed management of a vertebral fracture is used. For example, CPT code 22310 is for closed treatment of vertebral body fracture requiring bracing or casting. This code could be applied to an office visit with a patient with a burst fracture that was treated with a TLSO brace. There is a 90-day global period for that period, so all subsequent office visit in that 90-day period cannot be billed. Alternatively, one could bill for an evaluation and management code (e.g. 99203 for a new patient with low level of medical decision making). In this scenario, each time the patient returns to the office for a repeat check, an established patient evaluation and management CPT code (e.g. 99213 for a low level of medical decision making) can be applied to that visit.
In-Office Radiographs
In-office x-rays that were ordered and interpreted be the physician do not count towards medical decision making when billing for an evaluation and management. The interpretation of the imaging should be billed separately. However, if a physician interprets outside x-rays or an MRI that was done and documents the interpretation in the office note, that can count towards medical decision making. It would be an independent interpretation of a test or study. Copying a report is not the same as individually interpreting it. It should be documented in one’s own words and is best if it is clear that the image/study was individually interpreted. As an example, one could write in their note: MRI from 1/01/2025 of the lumbar spine was individually reviewed and interpreted showing L4/5 left-sided paracentral disc herniation causing lateral recess stenosis with no other significant stenosis seen.
Office Visits, ER consults, and Inpatient Consults
99024 – is not listed above and it is the code for post-operative visit during the global period
A couple of notes about the table: 1) the minimum time spent for each associated CPT code is in line with the code in the second column, 2) the purple codes are for inpatient codes, 3) the first code is for new patients, 4) the second code is for established patients, 5) the third code (in purple) is for a inpatient consult, 6) the fourth code (in purple) is for a subsequent hospital visit with the same patient
To use the table above, one should select the code billed either based on time or medical decision making. Time includes work done for the patient even outside of seeing or examining the patient. This means that time spent reviewing imaging, prior notes, or any other similar work counts towards the time spent for the evaluate and management service. To code based on medical decision making, one should use the problems addressed, data analyzed, and risk of complication columns. Pick the bullet point in the highest level of decision making (row) that is applicable for each of those columns. Then, select the highest level of decision making code (row) at which at least 2 out of 3 columns meet that criteria. For example: if an established patients comes in with acute exacerbation of chronic low back pain, an in-office x-ray is obtained that reveals no significant findings, and PT is ordered as an initial non-operative treatment. CPT code 99213 should be used. You can see below that a moderate level was selected for problems addressed, no data was analyzed (since in office x-rays are billed separately as noted above in the general tips), and a low risk of treatment was selected. Accordingly, 2 out of 3 met at least a low level of decision making so that associated code can be selected which is 99213 since this was an established patient.
Emergency Department Consultations
For patients with commercial insurance, one should use the outpatient office visit codes. The same CPT codes used based on the level of medical decision making or time spent just as is done for an office visit.
For Medicare and Medicaid patients, an ER consultation code should be used. These codes are 99282-99285. ER visits are not coded based on time so one should use the amount of medical decision making. To determine the amount of decision making, the same guidelines in the table above for outpatient and inpatient visits should be followed
Modifiers – Office
Cervical Codes
Thoracic Codes
Lumbar Codes
Peripheral Nerves
Stimulators and Catheters
Modifiers – Surgical
*Surgical Modifier 22
Modifier 22 can be used to signify a greater amount of work was performed than is standard. Common scenarios where this modifier gets applied is on the morbidly obese and in revision surgeries. Somewhere in the operative report, it should be documented how much longer the procedure took than usual, why it took longer than usual, and what multiple of the original code should be used. For example, say one had to perform a microdiscectomy on a morbidly obese patient due to significant neurologic deficit. In that operative report, one could write that the incision needed to be bigger, the dissection took an extra 30 minutes due to the significant soft tissue overlying the spine, and CPT code 63030 should be billed at 1.2x due to the added time and difficulty required to complete the case.