Lumbar Spinal Fusion (TLIF / PLIF)
[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
[***, 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 On the [right / left TLIF] side, a facetectomy was performed, and the nerve root was retracted.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. reporting options are identical to open TLIF — approach does not change reporting 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.
- Document the specific diagnosis driving fusion and its level (spondylolisthesis with grade, spondylolysis, stenosis with or without neurogenic claudication, or disc degeneration with radiculopathy), because each is coded separately. Instability, spondylolisthesis grade, and duration of failed conservative therapy are the key medical necessity elements for payer authorization.
Documentation & Reimbursement Considerations
- Primary service: Report Lumbar Spinal Fusion (TLIF / PLIF) as the primary service when it is the definitive operation performed.
- Primary code selection depends on approach and interbody technique: posterolateral fusion without an interbody cage (22.94 wRVU), posterior interbody fusion alone (PLIF, 21.54 wRVU), combined posterolateral plus posterior interbody fusion (TLIF, 26.13 wRVU), or anterior/lateral interbody fusion (ALIF, XLIF, OLIF, 22.94 wRVU), all with 90-day global periods. Virtually all TLIF procedures use the combined code because TLIF includes both an interbody cage and posterolateral arthrodesis. The posterior-interbody-only code describes PLIF, not TLIF.
- Each additional interspace has an add-on code paired with its specific primary (posterolateral 6.27, PLIF 5.09, TLIF 7.76, ALIF 5.38 wRVU). The add-ons are not interchangeable. Report one add-on per additional level fused.
- Posterior instrumentation is reported as non-segmental or as segmental by the number of vertebral segments spanned (3–6, 7–12, or 13 or more). Select based on the actual number of levels instrumented. The bilateral modifier is not allowed because these codes already account for bilateral instrumentation.
- Local autograft from the same incision is reportable but carries no Medicare payment. Morselized or structural autograft harvested through a separate skin incision is separately reimbursed (2.72 and 2.94 wRVU), so document the separate incision explicitly. Only one bone graft code is allowed per session.
- Interbody cage insertion is separately reportable with an add-on (4.14 wRVU) whenever a biomechanical cage is placed during TLIF or PLIF, with a further add-on for a cage at each additional interspace. This is a commonly missed add-on.
- Laminectomy or foraminotomy at the same interspace as a PLIF or TLIF is reported with a dedicated same-level decompression add-on (4.14 wRVU). Effective January 2022, this work is no longer bundled into the fusion primary codes. The standalone stenosis laminectomy code is bundled with PLIF/TLIF at the same interspace but remains reportable at a different interspace with a distinct-procedural-service modifier.
- Global period is 90 days. Return to the OR for a hardware complication is reported as an unplanned related return, while planned staged procedures (e.g., posterior fixation after a staged ALIF) use the staged-procedure modifier. For two-surgeon ALIF, the access surgeon and spine surgeon may each report the fusion with the co-surgery modifier, each receiving about 62.5% of the allowable. Document each surgeon's distinct role.
- Intraoperative neuromonitoring is reported by the independent monitoring neurophysiologist. The operating surgeon cannot separately report IONM because it is included in the surgical global package.