CPT® Code 0095T | Case2Code

Official Description

Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

Common Language Description

The CPT® Code 0095T refers to the procedure of removing a total disc arthroplasty, specifically an artificial disc, through an anterior approach at each additional interspace in the cervical region. This procedure is performed when there is a need to revise an existing cervical total-disc arthroplasty, which may involve the replacement of the artificial disc. The surgical approach begins with an incision made in the front of the neck, slightly off the midline of the spine, allowing access to the cervical spine. During the procedure, the esophagus is carefully retracted to provide a clear view of the surgical field. The surgeon identifies and protects critical structures such as nerves and arteries while dissecting the soft tissues of the neck to expose the spine. The intervertebral muscles are retracted to reveal the previously implanted artificial disc. If a revision is necessary, it may be due to various factors such as persistent pain, degenerative changes in the disc, or misalignment of the spine at the treated or adjacent disc spaces. The existing artificial disc is meticulously dissected from the end plates and removed. The surgeon assesses the extent of any bone loss or damage to the vertebral bodies to determine if a new disc can be successfully placed. Preparation of the intervertebral space for a new artificial disc involves milling and shaping the end plates above and below the disc space to ensure proper fit. Tension is applied to the vertebral bodies to facilitate the placement of the new artificial disc. Once inserted, the new disc is secured by pressing the surrounding metal plates into the prepared bony end plates, ensuring that the natural curvature of the cervical spine is maintained. After releasing the tension, the vertebral bodies compress the artificial disc, securing it in place. This code is specifically used to report each additional existing artificial disc being removed, following the separately reportable removal of the first disc, and is essential for accurate medical coding and billing in the context of cervical disc revision surgeries.

1. Indications

The procedure associated with CPT® Code 0095T is indicated for patients who require revision of an existing cervical total-disc arthroplasty. The specific indications for this procedure may include:

Persistent Pain: Patients experiencing ongoing discomfort or pain that may be attributed to the malfunction or failure of the previously implanted artificial disc.
Degenerative Changes: The presence of degenerative changes in the cervical spine that may affect the performance of the artificial disc, necessitating its removal and potential replacement.
Improper Alignment: Misalignment of the spine at the treated or adjacent disc spaces, which may lead to complications or inadequate function of the artificial disc.

2. Procedure

The procedure for CPT® Code 0095T involves several critical steps, which are detailed as follows:

Step 1: Anterior Approach Incision The surgeon begins by making an incision in the front of the neck, slightly off the midline of the spine. This approach provides direct access to the cervical spine while minimizing damage to surrounding structures.
Step 2: Retraction of Esophagus The esophagus is carefully retracted to create a clear surgical field, allowing the surgeon to visualize the cervical spine and the artificial disc that needs to be revised.
Step 3: Identification and Protection of Critical Structures During the dissection of soft tissues, the surgeon identifies and protects vital structures, including nerves and arteries, to prevent any potential injury during the procedure.
Step 4: Exposure of the Artificial Disc The intervertebral muscles are retracted to expose the previously implanted artificial disc, which is the focus of the revision procedure.
Step 5: Dissection and Removal of the Existing Disc The existing artificial disc is carefully dissected off the end plates and removed. The surgeon evaluates the condition of the vertebral bodies and assesses any bone loss or damage that may have occurred.
Step 6: Preparation for New Disc Placement If a new artificial disc is to be placed, the intervertebral space is prepared by milling and shaping the end plates above and below the disc space to ensure a proper fit for the new device.
Step 7: Insertion of the New Artificial Disc Tension is applied to the vertebral bodies above and below the disc space to facilitate the placement of the new artificial disc. Once positioned, the new disc is secured by pressing the surrounding metal plates into the prepared bony end plates.
Step 8: Final Adjustments The surgeon ensures that the normal cervical lordotic curvature is maintained during the insertion. After the new disc is in place, tension is released from the vertebral bodies, allowing them to compress the artificial disc and hold it securely in position.

3. Post-Procedure

Post-procedure care following the removal of a total disc arthroplasty involves monitoring the patient for any complications and ensuring proper recovery. Patients may be advised to follow specific rehabilitation protocols to facilitate healing and restore function. The surgeon will typically provide guidelines regarding activity restrictions, pain management, and follow-up appointments to assess the success of the procedure and the condition of the new artificial disc, if applicable. It is essential for patients to adhere to these recommendations to optimize recovery and minimize the risk of complications.

Short Descr	RMVL ARTIFIC DISC ADDL CRVCL
Medium Descr	RMVL TOT DISC ARTHRP ANT APPR CRV EA NTRSPC
Long Descr	Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
Status Code	Carriers Price the Code
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Inpatient Procedures, not paid under OPPS
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	P3D - Major procedure, orthopedic - other
MUE	1
CCS Clinical Classification	162 - Other OR therapeutic procedures on joints

This is an add-on code that must be used in conjunction with one of these primary codes.

22864

MPFS Status: Active Code APC C Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
AS	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
GC	This service has been performed in part by a resident under the direction of a teaching physician