Anterior Cervical Discectomy and Fusion (ACDF)
Cervical disc herniation / cervical spondylosis with radiculopathy / myelopathy
Same
Anterior cervical discectomy and fusion (ACDF), [C5-6 / C6-7 / specify levels], with anterior plating
[***, MD/DO]
[Resident/Fellow/PA name]
General endotracheal
Patient presents with [cervical radiculopathy refractory to ≥6 weeks of conservative management including PT, medications, and/or ESI / cervical myelopathy — no mandatory conservative trial required for myelopathy; surgical intervention is indicated for progressive or significant myelopathy]. MRI demonstrates [disc herniation / spondylotic stenosis] at [C5-6 / C6-7] with [foraminal narrowing / cord compression / T2 cord signal change at level]. [SSEP/MEP] baseline obtained. Risks including dysphagia, hoarseness (RLN injury), esophageal injury, vertebral artery injury, Horner syndrome, postoperative hematoma (airway-threatening), hardware failure, non-union, adjacent segment disease, [C5 palsy (multilevel cases),] and neurological worsening discussed.
After discectomy at [C5-6], [disc herniation / osteophyte complex] confirmed. Dural sac decompressed. Nerve root foramina unroofed [bilaterally / on the symptomatic side]. Endplates prepared to bleeding bone.
The patient was positioned supine with the neck gently extended. Neuromonitoring baselines established. A transverse incision was made in the right neck crease at the level of [C5-6], approximately 4 cm in length. Platysma divided transversely. The medial border of the sternocleidomastoid was identified and the dissection carried medial to the carotid sheath, retracting it laterally. The esophagus and trachea were retracted medially. The prevertebral fascia was incised.
Fluoroscopic localization confirmed the C5-6 interspace. Self-retaining retractors placed. The anterior disc space was entered with a scalpel and annulotomy performed. The disc was removed with a combination of pituitary rongeurs and curettes. The posterior longitudinal ligament was removed with a Kerrison rongeur. The spinal cord and bilateral nerve roots were visualized and confirmed decompressed. The endplates were prepared with a high-speed drill to bleeding cancellous bone.
A [PEEK / allograft] cage packed with [local autograft (from operative site) / demineralized bone matrix / rhBMP-2 (off-label use in anterior cervical spine — see 2008 FDA Public Health Notification for swelling/airway risk; documented informed consent obtained)] was sized and impacted into the disc space under fluoroscopic guidance with adequate lordosis. A [4-hole] anterior cervical plate was positioned and secured with [4] screws. Fluoroscopy confirmed appropriate hardware positioning and alignment.
The wound was irrigated. Retractors removed. Platysma and skin closed in layers. A drain was [placed / not placed]. Cervical collar applied. Patient tolerated the procedure well.
None
Disc material sent to pathology
Minimal to [X] mL
[Closed suction drain placed / None]
Patient extubated in OR. Taken to PACU / neurosurgical floor in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Cervical [disc herniation / spondylosis] with [radiculopathy / myelopathy] at ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Anterior cervical discectomy and fusion (ACDF), ***, with anterior plating
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with cervical [radiculopathy refractory to ≥6 weeks of conservative management / myelopathy (no conservative trial required)]. MRI demonstrates [disc herniation / spondylotic stenosis] at *** with [foraminal narrowing / cord compression / T2 cord signal change]. SSEP/MEP baseline obtained. Risks including dysphagia, hoarseness (RLN injury), esophageal injury, vertebral artery injury, Horner syndrome, postoperative hematoma, hardware failure, non-union, adjacent segment disease, and neurological worsening were discussed. Informed consent obtained.
FINDINGS: After discectomy at ***, [disc herniation / osteophyte complex] confirmed. Dural sac decompressed. Nerve root foramina unroofed [bilaterally / on the symptomatic side]. Endplates prepared to bleeding cancellous bone. Neuromonitoring stable throughout.
DESCRIPTION OF PROCEDURE:
Patient positioned supine with neck gently extended. Neuromonitoring baselines established. Transverse incision in right neck crease at level of ***, approximately 4 cm. Platysma divided transversely. Dissection carried medial to carotid sheath, retracting it laterally. Esophagus and trachea retracted medially. Prevertebral fascia incised. Fluoroscopic localization confirmed *** interspace. Self-retaining retractors placed. Discectomy performed with pituitary rongeurs and curettes. PLL removed with Kerrison rongeur. Spinal cord and bilateral nerve roots confirmed decompressed. Endplates prepared with high-speed drill to bleeding bone. A [PEEK / allograft] cage packed with [local autograft / BMP / DBM] sized and impacted under fluoroscopic guidance with adequate lordosis. [4-hole] anterior cervical plate secured with [4] screws. Fluoroscopy confirmed hardware position and alignment. Wound irrigated. Platysma and skin closed in layers. Cervical collar applied. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Disc material to pathology
COMPLICATIONS: None
DRAINS: [Closed suction drain / None]
DISPOSITION: Patient extubated in OR. Taken to PACU in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Two-level ACDF
Document each level separately. Document independent decompression at each level.
Cervical disc arthroplasty (CDA)
Motion-preserving alternative for selected 1-2 level radiculopathy. Document device type, size, endplate preparation, segmental mobility confirmed fluoroscopically, and absence of fusion material.
Corpectomy
For multilevel disease or OPLL. Document vertebral body removal, strut graft placement, and plating.
Charting Tips
- Document neuromonitoring use and any intraoperative changes
- State fluoroscopic level confirmation before skin incision
- Note approach side (right vs left) and structures retracted
- Document PLL removal if performed, as this indicates complete decompression
- State cage material, size, and bone graft used
- Document plate length, screw count, and fluoroscopic confirmation of position
Documentation & Reimbursement Considerations
- Primary service: Report Anterior Cervical Discectomy and Fusion (ACDF) as the primary service when it is the definitive operation performed.
- Report the single-level anterior cervical discectomy and fusion code for the first level (24.38 wRVU, 90-day global) and an add-on code for each additional level (6.34 wRVU per level). Add-on codes are exempt from the multiple-procedure reduction. Document each level treated and the decompression performed at each level.
- When arthrodesis is performed with minimal disc preparation and no therapeutic decompression, a separate anterior arthrodesis code (17.25 wRVU) applies instead. It is a primary code, not an add-on, and cannot be reported with the discectomy-and-fusion code at the same interspace. Most ACDF procedures use the discectomy-and-fusion code.
- When a PEEK or other synthetic interbody cage is implanted, report the interbody biomechanical device add-on (4.14 wRVU) in addition to the fusion codes. It is one of the most commonly missed ACDF add-ons. For a structural allograft spacer, report the structural allograft add-on (1.76 wRVU) instead, and never report both for the same interspace.
- Autograft harvested through a separate skin incision, such as the iliac crest, is separately reportable (2.72 wRVU morselized, 2.94 wRVU structural). Local autograft from the operative site (osteophyte shavings, drill debris) is bundled into the primary procedure and should not be reported as separate-incision autograft. Document the harvest site and graft type explicitly.
- A separate anterior cervical plate is reported with an anterior instrumentation add-on selected by the number of segments spanned (11.64 wRVU for 2–3 segments). Do not report plate instrumentation for stand-alone cages with integrated fixation, which are captured by the interbody device add-on.
- 90-day global period: collar management, physical therapy coordination, and routine follow-up are bundled. Reoperation for pseudarthrosis is reported as a staged or related procedure, not as an unplanned return to the operating room. Dysphagia and hoarseness are common, so document preoperative baseline swallowing and voice quality.