Lumbar Spinal Fusion (TLIF / PLIF)
2263322634wRVU: 7.76 — Arthrodesis, combined posterior or posterolateral + posterior interbody technique, each additional interspace (true add-on to 22633; 7.76 wRVU; ZZZ global — bill once per additional level)22842wRVU: 12.25 — Posterior segmental instrumentation, 3–6 vertebral segments (true add-on; 12.25 wRVU; ZZZ global — report with the primary fusion code; modifier 50 is prohibited for all 22840-22848 codes)22853wRVU: 4.14 — Insertion of interbody biomechanical device (cage) into intervertebral disc space (true add-on; 4.14 wRVU; ZZZ global — report once per interspace where a cage is placed; bill alongside the fusion primary code whenever an interbody cage is inserted)63052wRVU: 4.14 — Laminectomy, facetectomy, and foraminotomy at same level as arthrodesis, lumbar, single interspace (true add-on to 22630/22633; 4.14 wRVU; ZZZ global; established 2022 — separately reportable for decompression performed at the same interspace as PLIF or TLIF when a laminectomy/decompression is performed; was previously bundled into fusion codes before 2022)
[L4-5 / L5-S1 / multilevel] degenerative disc disease with [spondylolisthesis / stenosis / instability], refractory to conservative management, requiring surgical stabilization
Same
[L4-5 / L5-S1] posterior spinal fusion with [TLIF / PLIF] interbody cage and posterior segmental instrumentation, [X] levels
[Attending name], MD/DO
[Resident/PA name]
General endotracheal with intraoperative neuromonitoring (IONM): [MEP/SSEP / EMG]
The patient is a [age]-year-old [male/female] with [L4-5 degenerative spondylolisthesis Grade I / multilevel degenerative disc disease / isthmic spondylolisthesis] presenting with [axial low back pain / neurogenic claudication / radiculopathy] refractory to [X months] of conservative management. Imaging demonstrates [Grade I spondylolisthesis / disc collapse / foraminal stenosis]. Surgical stabilization and decompression were indicated. The risks, benefits, and alternatives were discussed and informed consent was obtained.
The operative levels were confirmed fluoroscopically. Decompression of the [L4-5 / L5-S1] levels demonstrated [thickened ligamentum flavum / facet hypertrophy / disc herniation compressing the traversing root]. Post-decompression, the [L5 / S1] nerve roots were freely mobile. The interbody space accepted a [X]-mm × [X]-mm interbody cage filled with [autograft / allograft / bone morphogenetic protein (rhBMP-2, off-label in this approach)].
The patient was positioned prone on a Jackson table with the abdomen free. IONM was established with baseline recordings obtained. Fluoroscopy confirmed the operative levels with a localizing needle.
A midline posterior incision was made over [L4–S1]. The lumbodorsal fascia was incised. Paraspinal muscles were elevated subperiosteally to the facet joints bilaterally. Self-retaining retractors were placed.
Pedicle screws were placed bilaterally at [L4] and [L5/S1] under fluoroscopic guidance: [5.5–7.5 mm × X mm] screws appropriate for lumbar anatomy. Electromyographic stimulation confirmed no medial wall breach (threshold well above the alert level, >12 mA on all screws). Rods were provisionally placed.
Laminectomy [/ laminotomy] was performed at [L4-5 / L5-S1], the ligamentum flavum was removed, and bilateral lateral recess decompression was performed. On the [right / left TLIF] side, a facetectomy was performed, and the nerve root was retracted. The disc space was prepared with sequential disc shavers and rasps to [X] mm height. The endplates were decorticated to bleeding bone.
A [PEEK / titanium expandable] interbody cage [X mm × X mm] packed with [local autograft / iliac crest autograft (separate incision) / allograft] was inserted under fluoroscopic guidance and confirmed in good position. Compression was applied across the construct. Decortication of the posterior elements was performed and [local autograft / allograft] was placed for posterolateral fusion.
IONM signals were stable throughout. Final fluoroscopy confirmed screw position, interbody cage position, and spondylolisthesis reduction [if applicable]. The wound was irrigated. Fascia was closed with [0-PDS]. Skin was closed with [2-0 Vicryl / staples].
None
Disc material and ligamentum flavum sent to pathology
[X] mL
[Hemovac drain in wound / no drain]
The patient was taken to the PACU in stable condition. Neurological status was assessed. Ambulation was initiated on postoperative day 1. DVT prophylaxis was initiated.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: L*** *** with spondylolisthesis/stenosis/instability
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: L*** posterior fusion with TLIF/PLIF interbody, PSI *** levels
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General + IONM (MEP/SSEP/EMG)
INDICATIONS: .PTAGE-year-old .PTSEX with L*** ***, failed conservative treatment *** months. Consent obtained.
FINDINGS: Level confirmed fluoro. Decompression: *** root freely mobile. Interbody: *** × *** mm cage, *** graft.
PROCEDURE:
Prone, Jackson table, abdomen free. IONM established; baselines obtained. Level confirmed with needle. Midline incision L***–***. Fascia incised. Paraspinals elevated to facets. Pedicle screws *** × *** mm bilateral L*** and ***. EMG: >12 mA threshold met, no medial breach on all screws. Rods provisionally placed. [Laminectomy/laminotomy], ligamentum flavum removed, bilateral decompression. [TLIF: facetectomy ***, root retracted, disc prep to *** mm, endplates decorticated.] *** cage inserted. Compression applied. Posterolateral autograft placed. IONM stable throughout. Final fluoro: screws/cage appropriate, [spondylolisthesis reduced]. Irrigated. Fascia 0-PDS. Closed.
EBL: *** mL
COMPLICATIONS: None
DISPOSITION: PACU, neuro check. Ambulate POD 1.
Signed: .ME, .MYDEGREE
.TODAYVariants
MIS-TLIF (Tubular Retractor)
Minimally invasive TLIF was performed via bilateral tubular retractors (METRx / X-Tube system). The paraspinal muscles were dilated rather than stripped. Pedicle screws were placed percutaneously through stab incisions under fluoroscopic guidance using a [Jamshidi needle / Longitude system]. The tubular retractor on the TLIF side allowed hemifacetectomy and interbody preparation. Rods were passed percutaneously through the percutaneous screw extenders. MIS-TLIF reduces paraspinal muscle injury, blood loss, and hospital stay compared to open fusion. CPT codes are identical to open TLIF — approach does not change code selection.
Charting Tips
- Document IONM baselines and any changes. MEP amplitude decreases >50% or SSEP latency increases >10% are standard alert thresholds — document any changes and the surgical response. Stable IONM throughout the case establishes the intraoperative neurologic baseline and is standard documentation for any significant spinal reconstruction. IONM is billed by the independent monitoring neurophysiologist, not the operating surgeon.
- Document pedicle screw placement confirmation method (fluoroscopy, O-arm CT, or EMG stimulation threshold). Document 'EMG threshold >12 mA, no medial breach' for each screw — the >12 mA threshold is the reassurance level; values of 6–10 mA are equivocal and should prompt investigation.
- Document spondylolisthesis reduction if applicable. Record pre- and post-reduction slip grades (percentage slip) to confirm correction and establish that reduction occurred intraoperatively.
- rhBMP-2 (Infuse) is FDA-approved only for single-level ALIF with the LT-CAGE via anterior approach at L4-S1. Use in TLIF, PLIF, or lateral approaches is off-label and carries elevated risk of heterotopic bone formation, radiculitis, and seroma. Document off-label use and informed consent discussion if rhBMP-2 is selected for a posterior approach.
- ICD-10: M43.16 (spondylolisthesis, lumbar region), M43.17 (spondylolisthesis, lumbosacral), M43.06 (spondylolysis, lumbar), M48.06 (spinal stenosis, lumbar, without neurogenic claudication), M48.061 (spinal stenosis, lumbar, with neurogenic claudication), M51.16 (disc disorder with radiculopathy, lumbar), M51.36 (disc degeneration, lumbar), M54.16 (radiculopathy, lumbar). Document the specific diagnosis driving fusion to support payer authorization — instability, spondylolisthesis grade, and failed conservative therapy duration are the key medical necessity elements.
Billing Tips
- Primary code selection is determined by approach and interbody technique: 22612 (posterolateral fusion only, no interbody component; 22.94 wRVU, 90-day global) — used when only posterolateral bone graft is placed, without an interbody cage. 22630 (posterior interbody fusion only, no posterolateral component, i.e., PLIF; 21.54 wRVU, 90-day global). 22633 (combined posterior or posterolateral + posterior interbody technique, i.e., TLIF; 26.13 wRVU, 90-day global) — the correct code for virtually all TLIF procedures because TLIF includes both an interbody cage and posterolateral decortication/arthrodesis. 22558 (anterior or anterolateral interbody fusion, i.e., ALIF, XLIF, OLIF; 22.94 wRVU, 90-day global). Do not mislabel 22630 as TLIF — it is PLIF. Do not mislabel 22633 as 'combined anterior + posterior' — it is combined posterior/posterolateral + posterior interbody.
- Add-on codes for each additional interspace: +22614 (posterolateral add-on to 22612; 6.27 wRVU, ZZZ global), +22632 (PLIF add-on to 22630; 5.09 wRVU, ZZZ global), +22634 (TLIF/combined add-on to 22633; 7.76 wRVU, ZZZ global), +22585 (ALIF add-on to 22558; 5.38 wRVU, ZZZ global). Each add-on code is paired with its specific primary — they are not interchangeable. Report one add-on per additional level fused.
- Posterior segmental instrumentation: 22840 (non-segmental, 12.21 wRVU), 22842 (segmental, 3–6 vertebral segments, 12.25 wRVU), 22843 (segmental, 7–12 vertebral segments, 13.10 wRVU), 22844 (segmental, 13 or more vertebral segments, 16.01 wRVU). Select based on the actual number of vertebral levels instrumented. Modifier -50 is explicitly prohibited for all 22840–22848 codes — these codes already account for bilateral instrumentation.
- Bone graft codes: +20936 (local autograft, same incision; reported as an add-on but carries $0 Medicare payment — reportable but not reimbursed; note it is not 'bundled' in the traditional sense but has zero wRVU). +20937 (morselized autograft from separate incision; 2.72 wRVU) and +20938 (structural bicortical/tricortical autograft from separate incision; 2.94 wRVU) are separately reimbursed when autograft is harvested through a separate skin incision. Document the separate incision explicitly to support 20937/20938 billing. Only one bone graft code per operative session is allowed — do not bill 20936 and 20937 together.
- Interbody cage insertion: +22853 (single interspace, 4.14 wRVU) is separately reportable whenever a biomechanical cage is placed during TLIF or PLIF. This is a commonly missed billing opportunity — every TLIF/PLIF that places a cage should include +22853. +22854 (each additional interspace for a second cage, 4.14 wRVU) if multiple cages are placed at separate levels.
- Same-level decompression: +63052 (laminectomy/decompression at the same interspace as arthrodesis, single level; 4.14 wRVU) is separately reportable when a laminectomy or foraminotomy is performed at the same level as PLIF (22630) or TLIF (22633). Effective January 2022, this work is no longer bundled into the fusion primary codes. CPT 63047 (standalone laminectomy for stenosis) is bundled with 22630/22633 at the same interspace by NCCI and should not be separately billed — use +63052 instead. 63047 remains separately reportable at a different interspace with modifier -59.
- Global period is 90 days. Return to OR for hardware complication uses modifier -78 (unplanned). Planned staged procedures (e.g., posterior fixation following staged ALIF) use modifier -58. Two-surgeon billing for ALIF: the access surgeon and spine surgeon each bill 22558-62 (co-surgery modifier); each receives approximately 62.5% of the normal CMS allowable. Document each surgeon's distinct role.
- Intraoperative neuromonitoring (IONM) is billed by the independent monitoring neurophysiologist using 95941 (per hour) or G0453 (Medicare). The operating surgeon cannot separately bill for IONM — it is included in the surgical global package.
General coding reference. Verify with your institution’s billing department before submitting claims.