CPT Coding for Posterior Cervical Decompression and Fusion C3-T1
For a posterior cervical decompression and fusion spanning C3 to T1 (4 vertebral segments), you will need to report multiple CPT codes to capture the decompression, instrumentation, and arthrodesis components of this procedure.
Primary Decompression Code
- CPT 63015 - Laminectomy with decompression of spinal cord and/or nerve roots, more than 2 vertebral segments; cervical 1, 2
- This code captures the multilevel posterior decompression across C3-C7 and into T1
Instrumentation Codes
- CPT 22842 - Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments 1, 3
Arthrodesis Codes
CPT 22600 - Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment 2, 3
CPT 22614 x3 - Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) 2, 3
- Report this code three times for the additional levels beyond the first level
- This covers the fusion at C3-C4, C4-C5, C5-C6, and C6-C7/T1
Bone Graft Code (if applicable)
- CPT 20937 or 20938 - Autograft for spine surgery only (includes harvesting the graft); morselized or structural, respectively 5
- Use the appropriate code based on whether you harvest local autograft or use structural graft
Critical Coding Considerations
Crossing the cervicothoracic junction (ending at T1 or T2) is associated with lower revision rates (2.6% at T1 vs 8.3% at C6) but increases operative time and blood loss 1
The procedure spanning C3-T1 involves 4 interspaces requiring fusion, which necessitates reporting the base arthrodesis code plus three add-on codes 2
Do not separately report foraminotomy codes if performed as part of the laminectomy, as this is considered inclusive 2
When the construct crosses into the thoracic spine at T1, ensure documentation clearly indicates the lowest instrumented vertebra to justify extension across the cervicothoracic junction 1, 4
Documentation Requirements
Clearly document the specific levels decompressed (C3, C4, C5, C6, C7, T1) 2
Document the type of instrumentation used (lateral mass screws vs pedicle screws) and at which levels 3
Note the indication for crossing the cervicothoracic junction, as this significantly impacts surgical complexity and complication rates 1, 6
Document estimated blood loss and operative time, as procedures extending to T2 average 343 minutes and 575mL blood loss compared to 215 minutes and 224mL at C6 1
Common Pitfalls to Avoid
Undercoding the number of arthrodesis levels - ensure you count each interspace being fused, not just the number of vertebrae instrumented 2
Failing to document medical necessity for crossing the cervicothoracic junction, which may be questioned by payers given the increased morbidity 1, 6
Not accounting for complications - dysphagia (37-46%), dysphonia (17%), and airway edema requiring reintubation (11-38%) are common with these extensive procedures and should be documented if they occur 4, 6