Coding Clarification: Instrumentation Removal vs. Exploration Based on Intent

Question:

Good afternoon,

I recently came across one of your Q&As from June 2025 that stated when spinal instrumentation is removed for the purpose of exploration, we would code the exploration CPT code 22830. This is helpful information; however, I am wondering if you can provide a reference for this. I would love to pass this information along to our providers, and a solid source would help to support it.

Answer:

In June 2025, the coding question was clarified:

CPT code 22830 should be billed if the intent for the procedure was for exploration.

If the intent is to explore the spinal fusion site, and instrumentation is removed only to allow that exploration, then CPT 22830 is reported. If the true intent is to remove the instrumentation (e.g., due to pain, infection, or hardware failure), and exploration is incidental, then only the instrumentation removal code is reported.

The National Correct Coding Initiative (NCCI) bundles certain codes based on the principle of standards of medical/surgical practice, which means: If a service is routinely performed as part of another procedure, it is considered integral and not separately reportable.

*This response is based on the best information available as of 01/22/26.