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The CPT® Code 22116 refers to the procedure of partial excision of a vertebral body specifically for the treatment of an intrinsic bony lesion. This procedure is performed without the need for decompression of the spinal cord or nerve roots and is applicable to a single vertebral segment. The term "partial excision" indicates that only a portion of the vertebral body is removed, which is typically necessary when a bony lesion is present. The procedure begins with an incision made over the affected vertebral segment or just lateral to the vertebra in question. The surrounding paravertebral muscles are then exposed, either by incision or retraction, to allow access to the vertebral body. Once the vertebral body is exposed, the surgeon locates the lesion and evaluates its extent, often using visual inspection and radiographic imaging to guide the procedure. The surgeon carefully maps out the amount of bone that needs to be removed to ensure complete excision of the lesion while protecting adjacent nerve roots and other vital structures. The removal of the bony lesion is typically accomplished using specialized instruments such as a high-speed bur and/or a curette. After the lesion has been completely excised, the incision is meticulously closed in layers to promote proper healing. It is important to note that this code is used for each additional vertebral segment involved in the procedure, and it should be listed separately in addition to the code for the primary procedure. For reference, related codes include 22110 for excision of a bone lesion of one cervical vertebral body, 22112 for a lesion of one thoracic vertebral body, and 22214 for a lesion of one lumbar vertebral body.
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The procedure associated with CPT® Code 22116 is indicated for the removal of intrinsic bony lesions located within the vertebral body. These lesions may present as tumors, cysts, or other abnormal growths that can compromise the structural integrity of the vertebra or potentially lead to neurological complications if left untreated. The decision to perform a partial excision is typically based on the evaluation of the lesion's characteristics, including its size, location, and the presence of any associated symptoms that may affect the patient's quality of life or spinal function.
The procedure begins with the surgeon making an incision over the affected vertebral segment or just lateral to the vertebra. This incision allows for access to the paravertebral muscles, which are then either incised or retracted to expose the vertebral body. Once the vertebral body is visible, the surgeon locates the intrinsic bony lesion. The extent of the lesion is evaluated through visual inspection and may also involve radiographic imaging to ensure accurate assessment. After determining the size and location of the lesion, the surgeon carefully maps out the area of bone that needs to be excised. The actual removal of the bony lesion is performed using a high-speed bur and/or a curette, with a focus on protecting the surrounding nerve roots and other vital structures during the process. Once the lesion has been completely excised, the surgeon proceeds to close the incision in layers, ensuring that the tissues are properly aligned to promote optimal healing.
Post-procedure care following the partial excision of a vertebral body involves monitoring the patient for any signs of complications, such as infection or excessive bleeding. Patients may be advised to limit physical activity and avoid heavy lifting for a specified period to facilitate healing. Pain management strategies may be implemented to address postoperative discomfort. Follow-up appointments are typically scheduled to assess the surgical site and ensure proper recovery. Additionally, imaging studies may be performed to confirm the complete removal of the lesion and to monitor the healing process of the vertebral body.
| Short Descr | REMOVE EXTRA SPINE SEGMENT | Medium Descr | PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM EA | Long Descr | Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | 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) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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 | 3 | CCS Clinical Classification | 142 - Partial excision bone |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 22110 | MPFS Status: Active Code APC C PUB 100 CPT Assistant Article Illustration for Code Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical | 22112 | MPFS Status: Active Code APC C CPT Assistant Article Illustration for Code Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic | 22114 | MPFS Status: Active Code APC C CPT Assistant Article Illustration for Code Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar |
| AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2017-01-01 | Note | AMA Guidelines changed. |
| 1996-01-01 | Added | First appearance in code book in 1996. |
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