Fusion · Spine

Surgical removal of a previously placed anterior spinal instrumentation system (plate, rod, or screw construct) from the front of the vertebral column.

Verified May 8, 2026 · 6 sources ↓

Medicare: $1,050.79
Total RVUs: 31.46
Global, days: 90
Region: Spine

Drawn from CMSCgsmedicareAAPCBillrazor

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Specify the spinal approach as anterior and identify the exact vertebral levels involved
Document the original implant type (plate, rod, screw, cage anchor) and the reason for removal (infection, failure, pain, pseudarthrosis)
State whether instrumentation was reinserted and, if so, whether it was at the same or a different level — this drives the reinsertion vs. removal code selection
Include intraoperative findings describing hardware condition (e.g., broken screw, loose plate, reactive tissue) to support medical necessity
Confirm that fluoroscopy, if used, is documented as intraoperative guidance integral to the procedure and not billed separately

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 51 Multiple procedures 58 Staged or related 59 Distinct service 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 22855 covers the operative removal of anterior spinal instrumentation — plates, rods, screws, or similar hardware — that was originally placed from an anterior surgical approach. Common indications include hardware failure, infection, pseudarthrosis, adjacent-segment pathology, or persistent pain attributable to the implant. The 90-day global period means any routine follow-up after this removal is bundled; billing an E/M during that window requires modifier 24 for unrelated visits or modifier 79 for unrelated surgical procedures in a separate return trip to the OR.

A critical distinction governs same-day reinsertion: if hardware is removed and reinserted at the same spinal level, report 22849 (reinsertion) — not 22855. If removal is at one level and new instrumentation placed at a non-overlapping level, code both the removal (22855) and the new instrumentation code separately. Per AANS guidance and NCCI policy, conflating these scenarios is a frequent unbundling or under-coding error.

NCCI bundles exploration of the surgical field (22830) into 22855 — do not report 22830 separately. Fluoroscopy used intraoperatively is also integral. With 296 known NCCI code pairs attached to 22855, pre-claim scrubbing against the NCCI PTP lookup is essential before submission.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	15.46
Practice expense RVU	11.1
Malpractice RVU	4.9
Total RVU	31.46
Medicare national rate	$1,050.79
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	$1,050.79
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 22855 get rejected.

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

Billing 22855 alongside 22849 when removal and reinsertion occurred at the same spinal level — only 22849 is reportable in that scenario
Unbundling 22830 (exploration) as a separate charge when it is included in the 22855 surgical package per NCCI
Missing medical necessity documentation — payers require explicit indication for removal (hardware failure, infection, etc.) in the operative note
Incorrect modifier use during the 90-day global period — E/M visits without modifier 24, or unrelated OR returns without modifier 79, will deny
Separately billing intraoperative fluoroscopy guidance, which is integral to the procedure and not independently payable

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01When do I use 22855 versus 22849?

Use 22849 when hardware is removed and reinserted at the same spinal level during the same operative session. Use 22855 when hardware is removed anteriorly and no reinsertion occurs, or when new instrumentation is placed at a non-overlapping level — in that case, bill both the removal and the new instrumentation code separately.

02Can I bill 22830 (exploration) with 22855?

No. Exploration of the surgical field is bundled into 22855 per NCCI and cannot be separately reported. Attempting to bill both will result in a bundling denial with no modifier override available.

03Is modifier 59 or XS needed when billing 22855 with another spinal procedure on the same date?

It depends on the specific code pair. Some NCCI pairs involving 22855 allow a modifier override (indicator 1) and some do not (indicator 0). Run the pair through the CMS NCCI PTP lookup tool before submitting. When procedures are at distinctly separate spinal levels, XS is appropriate if the edit allows it.

04What does the 90-day global period cover for 22855?

It covers the day-before preoperative visit, the surgery itself, and all routine postoperative care through day 90. Any E/M for an unrelated problem during that window needs modifier 24. A return to the OR for an unrelated procedure needs modifier 79. A planned staged procedure needs modifier 58.

05Can 22855 be billed with a new anterior instrumentation code if hardware is removed and replaced at a different level?

Yes. Per AANS guidance, if removal is at one level and new instrumentation is placed at a non-overlapping level, report the removal code (22855) and the new instrumentation code separately. Document the distinct levels clearly in the operative note to support both charges.

06Is intraoperative fluoroscopy separately billable with 22855?

No. Fluoroscopy used as guidance during the removal procedure is integral to 22855 and cannot be billed separately. If a distinct additional procedure on the same date independently requires fluoroscopic guidance, that imaging may be reportable separately with an appropriate NCCI-associated modifier.

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 anterior surgical approach, specific vertebral levels addressed, implant type removed, intraoperative findings, and the clinical indication for removal directly from dictation. It also flags whether any reinsertion occurred and at which level — the detail that determines whether 22855 or 22849 is the correct code. That prevents the same-level reinsertion miscoding that is one of the most common audit triggers for this procedure.

See how Mira captures CPT 22855 documentation