Spinal Surgery Functional Status and Quality of Life Outcome Specifications 2015 (01/01/2013 to 12/31/2013 Dates of Procedure) September 2014

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1 Description Methodology For patients ages 18 years and older who undergo a lumbar discectomy/laminotomy or lumbar spinal fusion procedure during the measurement year, the following measures will be calculated: 1. Average change between pre-operative and three months (6 to 20 weeks) post-operative functional status as measured with the Oswestry Disability Index, version 2.1a. 2. Average change between pre-operative and three months (6 to 20 weeks) post-operative health related quality of life as measured with the EQ5D-5L tool. 3. Average change between pre-operative and three months (6 to 20 weeks) post-operative back pain as measured with the visual analog scale (VAS) for pain. 4. Average change between pre-operative and three months (6 to 20 weeks) post-operative leg pain as measured with the visual analog scale (VAS) for pain. 5. Average change between pre-operative and one year (9 to 15 months) postoperative functional status as measured with the Oswestry Disability Index, version 2.1a. 6. Average change between pre-operative and one year (9 to 15 months) postoperative health related quality of life as measured with the EQ5D-5L. 7. Average change between pre-operative and one year (9 to 15 months) postoperative back pain as measured with the visual analog scale (VAS) for pain. 8. Average change between pre-operative and one year (9 to 15 months) postoperative leg pain as measured with the visual analog scale (VAS) for pain. Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review. Full population data is required. Page 1

2 Rationale Overall, spine surgery rates have declined slightly from 2002 to 2007, but the rate of complex spinal fusion procedures has increased 15-fold, from 1.3 to 19.9 per 100,000 Medicare beneficiaries. Complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex spinal fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex spinal fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50 to 3.49). 1 Minnesota, as compared to national Medicare statistics, 2 demonstrates a lumbar spinal fusion rate that is four times the national average [0.84 per 1000 enrollees as compared to 0.2 per 1000]. Spinal fusion has become one of medicine s most controversial procedures. Some surgeons argue that spinal fusion is appropriate only for a small number of conditions, such as spinal instability, spinal fracture or severe curvature of the spine and that the financial incentives have caused the procedure to become overused. Others say that it is a useful tool to treat patients who have debilitating back pain and have tried other options like physical therapy to no avail. 3 Procedure Measurement Period For consumers, there is a lack of publicly reported information that would provide patients with an understanding of potentially how well they will function after having lumbar spinal surgery. These measures will provide outcome data for patients that currently do not exist. Measurement period will be for patients undergoing a procedure between 01/01/2013 and 12/31/ Trends, Major Medical Complications and Charges Associated with Surgery for Lumbar Spinal Stenosis in Older Adults Deyo. 2 Dartmouth Atlas of Health Care: Studies of Surgical Variation- Spine Surgery 3 Top Spine Surgeons Reap Royalties, Medicare Bounty- Wall Street Journal December 2010 Page 2

3 Denominator Patient Population 1 Lumbar Discectomy/ Laminotomy Patients who meet each of the following criteria are included in the population: Patients age 18 years and older at the start of the procedure measurement period (date of birth was on or prior to 01/01/1995; no upper age limit). Patients who underwent a lumbar discectomy/laminotomy procedure for a diagnosis of disc herniation with the date of procedure between 01/01/2013 and 12/31/2013. Patient had following CPT Code: See Table 1. Include the patient in the lumbar discectomy/laminotomy population only if CPT diagnosis code is the only spine procedure code used. Do not include the patient if they have an additional spinal procedure (CPT) performed. Patient had following ICD-9 Diagnosis Code: See Table 2. This diagnosis code can be in any position Eligible specialties: Orthopedic surgery, Neurosurgery Eligible providers: Orthopedic surgeons and Neurosurgeons who perform lumbar discectomy/laminotomy procedures. Exclusions Population 1 None Page 3

4 Denominator Patient Population 2 Lumbar Spinal Fusion Patients who meet each of the following criteria are included in the population: Patients age 18 years and older at the start of the procedure measurement period (date of birth was on or prior to 01/01/1995; no upper age limit). Patients who underwent a lumbar spinal fusion procedure for a diagnosis of disc herniation with the date of procedure between 01/01/2013 and 12/31/2013. If any portion of the lumbar spine is fused (L1 to L5), the patient is to be included If the fusion of the lumbar spine also incorporates thoracic vertebrae, the patient is to be included Patient had following CPT Codes: 22533, 22534, 22558, , 22630, See Table 3. Eligible specialties: Orthopedic surgery, Neurosurgery Eligible providers: Orthopedic surgeons and Neurosurgeons who lumbar spinal fusion procedures. Exclusions Population 2 The following are exclusions: Cancer, fracture and infection related to the spine. See Table 4, Table 5 and Table 6. Idiopathic and congenital scoliosis. See Table 7. Measures Patient Population 1 Lumbar Discectomy/ Laminotomy Measures for the lumbar discectomy/laminotomy population three months (6 weeks to 20 weeks) postoperatively include: 1. Average change between pre-operative and three months (6 to 20 weeks) postoperative functional status as measured with the Oswestry Disability Index, version 2.1a. 2. Average change between pre-operative and three months (6 to 20 weeks) postoperative health related quality of life as measured with the EQ5D-5L tool. 3. Average change between pre-operative and three months (6 to 20 weeks) postoperative back pain as measured with the visual analog scale (VAS) for pain. 4. Average change between pre-operative and three months (6 to 20 weeks) postoperative leg pain as measured with the visual analog scale (VAS) for pain. Page 4

5 Patient Population 2 Lumbar Spinal Fusion Measures for the lumbar spinal fusion population one year (9 to 15 months) postoperatively include: 1. Average change between pre-operative and one year (9 to 15 months) postoperative functional status as measured with the Oswestry Disability Index, version 2.1a. 2. Average change between pre-operative and one year (9 to 15 months) postoperative health related quality of life as measured with the EQ5D-5L. 3. Average change between pre-operative and one year (9 to 15 months) postoperative back pain as measured with the visual analog scale (VAS) for pain. 4. Average change between pre-operative and one year (9 to 15 months) postoperative leg pain as measured with the visual analog scale (VAS) for pain. Codes used to Identify Patients who Underwent Lumbar Discectomy/Laminotomy Procedure Table 1: CPT Codes for Identifying Lumbar Discectomy/Laminotomy Procedure CPT Procedure Code CPT Procedure Code Description Laminotomy (hemilaminectomy), with decompression of the nerve root(s), including partial facetectomy, foraminotomy and /or excision of herniated intervertebral disc, including open and endoscopically-assisted procedures, 1 interspace, lumbar. Table 2: ICD Codes for Identifying Lumbar Discectomy/Laminotomy Procedure ICD Diagnosis Code ICD Diagnosis Code Description Displacement of lumbar intervertebral disc without myelopathy Codes used to Identify Patients who Underwent Lumbar Spinal Fusion Procedure Table 3: CPT Codes for Identifying Lumbar Spinal Fusion Procedure CPT Procedure Code CPT Procedure Code Description Arthrodesis, lateral extracavitary tech including minimal discectomy to prepare interspace, lumbar Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace thoracic or lumbar, each add segment Page 5

6 CPT Procedure Code Spinal Surgery Functional Status and CPT Procedure Code Description Arthrodesis, anterior interbody tech including minimal discectomy to prepare interspace, lumbar Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace Arthrodesis, posterior technique, with or without lateral transverse technique, lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy, lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment, lumbar Codes used to Identify Patients who Meet Exclusion Criteria Table 4: ICD-9 Codes for Identifying Patients who had Cancer Related to the Spine Malignant neoplasm bone & cartilage vertebral column Malignant neoplasm bone & cartilage pelvic, sacrum, coccyx Secondary malignant neoplasm ; bone and bone marrow Benign neoplasm bone & cartilage vertebral column Benign neoplasm bone & cartilage pelvic, sacrum, coccyx Neoplasm uncertain behavior bone & cartilage Neoplasm unspecified nature bone & cartilage Table 5: ICD-9 Codes for Identifying Patients who had Fracture Related to the Spine Fracture, lumbar closed Fracture, lumbar open Page 6

7 805.6 Fracture, sacrum & coccyx closed Fracture, sacrum & coccyx open Fracture w/spinal cord injury, lumbar closed Fracture w/spinal cord injury, lumbar open Fracture w/spinal cord injury, sacrum, coccyx closed unspecified Fracture w/spinal cord inj, sac/cocc closed cauda equina lesion Fracture w/spinal cord inj, sac/cocc closed cauda equina other Fracture w/spinal cord inj, sac/cocc closed other spinal cord inj Fracture w/spinal cord injury, sacrum, coccyx open unspecified Fracture w/spinal cord inj, sac/coccyx open cauda equina lesion Fracture w/spinal cord inj, sac/coccyx open cauda equina other Fracture w/spinal cord inj, sac/coccyx open other spinal cord inj Pathologic fracture of vertebrae Non-union of fracture (pseudoarthrosis) Late effect fracture of the spine and trunk without mention of spinal cord lesion Table 6: ICD-9 Codes for Identifying Patients who had Infection Related to the Spine Acute osteomyelitis; pelvic region and thigh Acute osteomyelitis; other specified sites Acute osteomyelitis; multiple sites Chronic osteomyelitis; pelvic region and thigh Chronic osteomyelitis; other specified sites Chronic osteomyelitis; multiple sites Unspecified osteomyelitis; pelvic region and thigh Unspecified osteomyelitis; other specified sites Unspecified osteomyelitis; multiple sites Page 7

8 ICD-9 Diagnosis Codes Spinal Surgery Functional Status and ICD-9 Diagnosis Codes Description Periostitis without mention of osteomyelitis; pelvic region and thigh Periostitis without mention of osteomyelitis; other specified sites Periostitis without mention of osteomyelitis; multiple sites Osteopathy resulting from poliomyelitis; pelvic region and thigh Osteopathy resulting from poliomyelitis; other specified sites Osteopathy resulting from poliomyelitis; multiple sites Other infections involving bone in diseases classified elsewhere; pelvic region and thigh Other infections involving bone in diseases classified elsewhere; other specified sites Other infections involving bone in diseases classified elsewhere; multiple sites Unspecified infection of bone; pelvic region and thigh Unspecified infection of bone; other specified sites Unspecified infection of bone; multiple sites Table 7: ICD-9 Codes for Identifying Patients who had Idiopathic or Congenital Scoliosis Scoliosis and kyphoscoliosis, idiopathic Resolving infantile idiopathic scoliosis Progressive infantile idiopathic scoliosis Scoliosis due to radiation Thoracogenic scoliosis Scoliosis and kyphoscoliosis, other Congenital deformity of the spine, postural lordosis or scoliosis Page 8

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