Three-column thoracic spine osteotomy via posterior or posterolateral approach, resecting one vertebral segment including pedicles and posterior vertebral wall — the pedicle subtraction osteotomy (PSO) at the thoracic level.
Verified May 8, 2026 · 5 sources ↓
- Medicare
- $2,285.29
- Total RVUs
- 68.42
- Global, days
- 90
- Region
- Spine
Documentation requirements
What must appear in the operative or office note to support the claim.
Source · Editorial brief grounded in 5 cited references ↓
- Operative note must identify the specific thoracic vertebral level(s) resected and confirm a three-column approach — lamina, both pedicles, and posterior vertebral wall
- Clearly distinguish PSO from posterior column osteotomy (Ponte/Smith-Petersen); document that all three columns were addressed in a single vertebral segment
- Indication documented in the medical record: spinal deformity diagnosis (e.g., fixed kyphosis, post-traumatic deformity, flatback syndrome) with imaging correlation
- If 22208 is reported for an additional level, the operative note must independently describe the osteotomy at the second segment — not a reference back to the primary level
- Neuromonitoring records retained if intraoperative MEP/SSEP was used — payers may request these for high-RVU spine procedures
- Pre-op and post-op imaging documenting deformity magnitude and correction achieved
Applicable modifiers
Modifiers commonly billed with this code.
Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual
What this code covers
Source · Editorial summary grounded in 5 cited references ↓
22206 covers a pedicle subtraction osteotomy (PSO) of the thoracic spine performed through a posterior or posterolateral approach. The procedure involves removing the entire lamina of the targeted vertebra, ligamentum flavum, portions of adjacent interspaces, both pedicles, part of the lateral vertebral wall, and the posterior vertebral wall — fully exposing the spinal cord and bilateral nerve roots. This is a true three-column resection, which is what separates it from single-column posterior osteotomies coded under 22210–22216.
Added to the CPT system in 2008 specifically to capture the substantially greater work and risk of a three-column versus posterior-column-only osteotomy, 22206 is the thoracic counterpart to 22207 (lumbar PSO). If a PSO is performed at an additional vertebral segment during the same session, report 22208 as an add-on. Do not use 22206 for a Smith-Petersen or Ponte osteotomy — those single-column procedures belong under 22210 or 22212.
22206 carries a 90-day global period. Arthrodesis codes (22800–22804 for posterior, 22806–22812 for anterior) are separately reportable and typically required alongside a PSO since the osteotomy is performed as part of deformity correction and fusion. Instrumentation add-on codes also apply. Bill 22206 in a facility setting — this procedure does not occur in a non-facility environment.
RVU & reimbursement
Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.
Source · CMS Physician Fee Schedule, RVU26A · January 2026
| Work RVU | 36.25 |
| Practice expense RVU | 20.14 |
| Malpractice RVU | 12.03 |
| Total RVU | 68.42 |
| Medicare national rate | $2,285.29 |
| Global period | 90 days |
Payment by site of service
Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.
Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026
| Setting | Medicare rate (national) |
|---|---|
Office (PFS non-facility) Procedure performed in physician's office | $2,285.29 |
HOPD (APC 5114) Hospital outpatient department | $7,413.38 |
ASC (PI G2) Ambulatory surgical center (freestanding) | $3,695.53 |
Common denial reasons
The recurring reasons claims for CPT 22206 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Upcoding challenge: payer downcodes 22206 to a posterior-column osteotomy (22210/22212) when the operative note fails to explicitly document resection of both pedicles and the posterior vertebral wall
- Unbundling dispute: arthrodesis codes (22800–22812) denied as inclusive when payer incorrectly treats them as bundled into 22206 — they are separately reportable and should be appealed with CPT guidelines
- Missing or vague level documentation: denial for lack of specificity when the operative note says 'mid-thoracic' without naming the vertebral segment (e.g., T8)
- Medical necessity denial when pre-authorization was not obtained or deformity severity is not substantiated by imaging and clinical notes
- Add-on code 22208 denied when the primary code 22206 is missing or rejected — always resolve the primary code before appealing the add-on
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 5 cited references ↓
01What's the difference between 22206 and 22210?
02Can I bill 22206 and arthrodesis codes together?
03When do I use add-on code 22208?
04Is modifier 62 appropriate for 22206 when two surgeons operate?
05Does the 90-day global period affect post-op billing?
06Can 22206 be billed with modifier 22 for an unusually complex case?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
Mira AI Scribe
Mira's AI scribe captures the approach (posterior vs. posterolateral), the specific thoracic vertebral level, and explicit confirmation that all three columns were addressed — lamina, bilateral pedicles, and posterior vertebral wall. It also flags whether an additional-level osteotomy (22208) or co-surgeon arrangement (modifier 62) applies. This prevents the most common audit trigger: an operative note that describes a Ponte or Smith-Petersen osteotomy in language indistinguishable from a PSO, inviting a downcode to 22210 or 22212.
See how Mira captures CPT 22206 documentation