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Official Description

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar; each additional interspace (List separately in addition to code for primary procedure)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Arthrodesis, specifically the posterior interbody technique, is a surgical procedure aimed at fusing one or more intervertebral joints in the lumbar region of the spine. This technique is often employed to address conditions such as vertebral fractures or instability, which can lead to significant pain and functional impairment. The procedure involves making an incision in the back to access the affected lumbar vertebrae. Once the incision is made, the surrounding soft tissues are carefully dissected to expose the vertebrae, allowing for direct access to the intervertebral disc. The posterior interbody fusion technique may be performed in conjunction with other surgical interventions, such as laminectomy or discectomy, to adequately prepare the interspace for fusion. The removal of the intervertebral disc is a critical step, as it allows for the preparation of the joint space where the fusion will occur. The procedure may also involve the use of bone grafts, which can be harvested from the patient's iliac crest or obtained from a bone bank, to facilitate the fusion process. The ultimate goal of this procedure is to stabilize the spine and alleviate pain by promoting the fusion of the vertebrae, thereby restoring normal function and mobility to the affected area.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Arthrodesis using the posterior interbody technique is indicated for various conditions affecting the lumbar spine. The following are explicitly provided indications for this procedure:

  • Vertebral Fracture - This procedure is performed to stabilize fractures in the lumbar vertebrae, which may compromise spinal integrity and lead to pain or neurological deficits.
  • Vertebral Instability - Conditions that result in instability of the vertebral joints, potentially leading to pain and functional impairment, are also indications for this surgical intervention.

2. Procedure

The posterior interbody arthrodesis procedure involves several critical steps to ensure successful fusion of the lumbar vertebrae. The following procedural steps are outlined:

  • Step 1: Incision and Exposure - A surgical incision is made in the back over the affected lumbar vertebral joints. The surgeon carefully dissects the soft tissues to expose the vertebrae, ensuring minimal damage to surrounding structures.
  • Step 2: Muscle Retraction and Laminectomy - The muscles are retracted away from the lamina, allowing for better access to the vertebral bodies. A bone drill is then utilized to remove a portion of the lamina, which is necessary for preparing the interspace for fusion.
  • Step 3: Discectomy - The intervertebral disc is excised to prepare the joint space for arthrodesis. This step is crucial as it clears the area for the placement of the bone graft.
  • Step 4: Bone Graft Preparation - A bone graft is obtained, which may be harvested from the iliac crest or sourced from a bone bank. This graft is prepared for placement in the intervertebral joint space to facilitate fusion.
  • Step 5: Graft Placement - The prepared bone graft is inserted into the intervertebral joint space, providing the necessary biological material for fusion.
  • Step 6: Internal Fixation - Drill holes are created in the facets or spinous processes of each vertebra. Wires are threaded through the vertebrae to immobilize the joint. Alternatively, other internal fixation devices may be placed through the pedicles or facets to enhance stability.
  • Step 7: Drain Placement and Closure - A drain may be placed to prevent fluid accumulation, and the surgical wound is then closed in layers to promote healing.

3. Post-Procedure

Post-procedure care following posterior interbody arthrodesis typically involves monitoring for complications and managing pain. Patients may require a period of immobilization to allow for proper healing and fusion of the vertebrae. Physical therapy may be initiated to aid in recovery and restore mobility. Follow-up appointments are essential to assess the healing process and ensure that the fusion is progressing as expected. Additional considerations may include managing any surgical drains and monitoring for signs of infection or other complications.

Short Descr ARTHRD PST TQ 1NTRSPC LM EA
Medium Descr ARTHRODESIS POSTERIOR INTERBODY 1 NTRSPC EA ADDL
Long Descr Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar; each additional interspace (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) 2 - Co-surgeons permitted and no documentation required if the two- specialty requirement is met.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Items and Services Packaged into APC Rates
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P3D - Major procedure, orthopedic - other
MUE 4
CCS Clinical Classification 158 - Spinal fusion

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

22612 MPFS Status: Active Code APC J1 ASC J8 Physician Quality Reporting CPT Assistant Article Illustration for Code Arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral transverse technique, when performed)
22630 MPFS Status: Active Code APC J1 Physician Quality Reporting CPT Assistant Article Illustration for Code Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar;
22633 MPFS Status: Active Code APC J1 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar;
63052 Add-on Code Resequenced Code MPFS Status: Active Code APC N Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure)
63053 Add-on Code Resequenced Code MPFS Status: Active Code APC N Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional vertebral segment (List separately in addition to code for primary procedure)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
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).
GC This service has been performed in part by a resident under the direction of a teaching physician
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.
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.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
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.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
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Action
Notes
2024-01-01 Changed First appearance of change in codebook.
2022-01-01 Note Short and Medium description changed.
2022-01-01 Changed Long description changed per CPT Errrata & Technical Corrections dated 2021-12-30
2011-01-01 Note Short description changed.
2007-01-01 Changed Code description changed.
1996-01-01 Added First appearance in code book in 1996.
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