Fusion · Spine

Open treatment of an odontoid process fracture or dislocation using internal fixation (screws or wires) without bone graft application.

Verified May 8, 2026 · 5 sources ↓

Medicare: $1,624.62
Total RVUs: 48.64
Global, days: 90
Region: Spine

Drawn from CMSAAPCCgsmedicare

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 5 cited references ↓

Fracture classification (Anderson-D'Alonzo type, e.g., Type II) documented in H&P and operative note
Imaging confirming odontoid fracture or fracture-dislocation (CT cervical spine preferred; plain films acceptable if CT unavailable)
Operative note specifying anterior approach, reduction technique, and fixation hardware used (screw vs. wire)
Explicit documentation that no bone graft was harvested or applied — required to distinguish 22318 from 22319
Intraoperative fluoroscopy or imaging guidance noted (even if not billed separately, confirms reduction was confirmed radiographically)
Medical necessity narrative addressing why surgical fixation was chosen over immobilization (instability, displacement, patient factors)

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 51 Multiple procedures 52 Reduced services 57 Decision for surgery 58 Staged or related 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

CPT 22318 covers open anterior treatment of an odontoid (dens) fracture or fracture-dislocation at the C2 level. The surgeon makes an anterior cervical incision, reduces the fracture under fluoroscopic guidance, and stabilizes it with screw or wire fixation — without harvesting or applying a bone graft. The no-graft distinction is the key differentiator from 22319, which includes grafting.

This is a high-complexity spinal procedure with a 90-day global period. That global covers the day-before visit, the surgery itself, and all routine postoperative management through day 90. Any E/M services for unrelated conditions during the global window require modifier 24. A staged or planned return procedure in the post-op period needs modifier 58; an unplanned return for a related complication uses modifier 78; an unrelated procedure by the same surgeon during the global uses modifier 79.

Odontoid fractures are classified by the Anderson-D'Alonzo system (Types I, II, III). Type II fractures — through the base of the dens — are the most common indication for 22318. The operative note must clearly document fracture type, fixation method, and the explicit decision not to use a graft. Payers routinely request records to confirm medical necessity for surgical versus conservative management, particularly in elderly patients where non-union risk drives operative decisions.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	22.15
Practice expense RVU	17.52
Malpractice RVU	8.97
Total RVU	48.64
Medicare national rate	$1,624.62
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	$1,624.62
HOPD (APC 5115) Hospital outpatient department	$13,116.76
ASC (PI G2) Ambulatory surgical center (freestanding)	$6,804.43

Common denial reasons

The recurring reasons claims for CPT 22318 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Missing graft/no-graft distinction in operative note — payer cannot differentiate 22318 from 22319 without explicit documentation
Insufficient medical necessity documentation for operative versus conservative management, especially in elderly or low-demand patients
Fracture type not specified in operative or clinical records, triggering medical review or downcoding
Unbundling of fluoroscopic guidance when the imaging is considered integral to the open spinal fracture procedure
Global period violation — postoperative E/M claims within 90 days submitted without modifier 24 or 79 when required

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01What is the difference between CPT 22318 and 22319?

22318 is open treatment of an odontoid fracture without bone graft. 22319 includes bone graft application. The operative note must explicitly state whether a graft was or was not used — payers and auditors cannot infer it.

02Can 22318 be billed with fluoroscopy guidance codes on the same claim?

Generally no. Intraoperative fluoroscopy used to confirm reduction and fixation placement is considered integral to open spinal fracture treatment and should not be reported separately. NCCI policy bundles radiologic guidance that is standard to the procedure.

03What modifier applies if a co-surgeon assists on this case?

Use modifier 62 if two surgeons of different specialties each perform distinct portions of the procedure and each dictates their own operative note. Use modifier 80 for a traditional assistant surgeon, or AS if the assistant is a PA, NP, or CNS.

04What ICD-10 codes are typically linked to 22318?

Type II odontoid fractures (S12.11x series) and Type III (S12.13x series) are the most common pairings. Type I (S12.010–S12.011) rarely requires open fixation. Include the appropriate 7th character for initial encounter (A) or subsequent care. Confirm your payer's accepted diagnosis list before submitting.

05Does the 90-day global period apply if the procedure is performed in an ASC?

Yes. The global period follows the surgeon, not the facility. The 90-day global applies regardless of whether 22318 is performed in a hospital or ASC. All routine post-op visits within 90 days are bundled into the surgical payment.

06When should modifier 22 be used with 22318?

Append modifier 22 when the procedure required substantially greater work than typical — for example, severe displacement requiring prolonged reduction, morbid obesity complicating the anterior approach, or multilevel instability addressed in the same session. Document the specific reasons in a cover letter or operative addendum; without it, payers will deny the upward adjustment.

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 fracture classification (Anderson-D'Alonzo type), approach (anterior cervical), fixation method (screw vs. wire), reduction technique, and the explicit absence of bone graft from dictation. That last detail — no graft applied — is what distinguishes 22318 from 22319 and prevents downcoding or upcoding flags on audit.

See how Mira captures CPT 22318 documentation