Spine Surgery Coding: Don t Break Your Neck Trying to Figure It Out

Transcription

1 Spine Surgery Coding: Don t Break Your Neck Trying to Figure It Out Presented to: AAPC Annual Meeting Orlando, Florida April 15, 2013 Presented by: Kim Pollock, RN, MBA, CPC

2 Kim Pollock, RN, MBA, CPC Consultant and Speaker Kim Pollock specializes in streamlining the operations of neurosurgical practices. Kim has thirty years experience in health care as a nurse, administrator and consultant. For over thirteen years, Ms. Pollock has helped large group practices, as well as academic and solo practices, improve collections and efficiency. She is expert at auditing neurosurgery coding and documentation. Ms. Pollock understands the complexity of coding and reimbursement issues specific to neurological surgeons both from a clinical perspective and from a payor side. She is an expert in analyzing chart documentation and in reengineering practices to enhance the reimbursement process. She has presented seminars and workshops for physicians and their staff on behalf of the American Association of Neurological Surgeons and the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS). Ms. Pollock has also conducted programs for the American Academy of Procedural Coders, the North American Spine Society, the American Neurotology Society and the Congress of Neurological Surgeons. Based on her previous years of administrative experience, Ms. Pollock has a unique understanding of the challenges facing academic medicine both clinically and organizationally. She has served as the Administrator of the Department of Otorhinolaryngology as well as Associate Vice President of Cancer Programs at the University of Texas Southwestern Medical School in Dallas. Ms. Pollock was the representative for the AAO-HNS on the clinical practice expert paneltechnical group (CPEP-TEG) convened by CMS (formerly HCFA) to redetermine the practice expense portion of RBRVS. She served two terms on the Board of Directors for the Society of Otorhinolaryngology and Head-Neck Nurses, Inc. (SOHN) and has served on the Board for the Ear, Nose and Throat Nursing Foundation. Ms. Pollock is the recipient of the prestigious Presidential Citation Award from the SOHN as well as an Honor Award from the AAOHNS. Ms. Pollock holds a Masters of Business Administration Degree as well as a Bachelors of Science Degree in Nursing. She is also a certified coder through the AAPC. KZA Disclaimer This manual is not intended to provide legal advice to physicians and their staffs. If you have specific questions regarding the permissibility of your billing or other practices, we recommend that you consult legal counsel directly for assistance in evaluating any legal, regulatory or compliance issues regarding these matters. In the event that you choose to consult with outside legal counsel, KZA is available to work with such counsel, as appropriate, to meet your needs. CPT five digit codes, nomenclature and other data are copyright 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. 2

3 Global Surgical Package Surgical CPT Code Preoperative Period Intraoperative Time Postoperative Global Period Incision and Approach Resection or Repair Closure Exception: The skull base surgery codes consider an approach and definitive codes as separate stand-alone codes. Pre-op Period Intra-op Service Post-op Period CPT Says Subsequent to the decision for surgery, one related E&M encounter on the date immediately prior to or on the date of procedure (including history and physical) Local infiltration, metacarpal/ metatarsal/digital block or topical anesthesia. Moderate (conscious) sedation may be reported as indicated in CPT Immediate postoperative care, including dictating operative notes, talking with the family and other physicians Writing orders Evaluating the patient in the postanesthesia recovery area Pain management services Intraoperative nerve monitoring by the surgeon Typical follow-up care Medicare Says E&M in which the decision is made is separately billable. Visits to perform history and physicals are not separately reportable. Major procedure has a preoperative global period of day before and day of the procedure Minor procedure has a preoperative global period of the day of the procedure Anesthesia of any kind given by the operating surgeon. Exception: moderate (conscious) sedation may be reported by the surgeon when appropriate. Discussion with patient/family about the nature of the procedure, alternative treatment risks, benefits and other informed consent issues Scheduling surgery Writing preoperative admission notes and orders Dictating the operative record Writing postoperative orders and postoperative prescribed care Postoperative pain management including catheter placement by operating surgeon Intraoperative nerve monitoring by the surgeon Follow-up care including treatment of complications unless they require a return to the operating room for the prescribed follow-up period Major procedure has a postoperative global period of 90 days Minor procedure has a postoperative global period of 0 or 10 days Remember: Placement of a pain delivery catheter is not separately reportable for the surgeon (not even using an unlisted code). 3

4 Global Surgical Package CAN I BILL FOR A PREOP VISIT? From CPT Assistant, May 2009: Q: Are preoperative visits billable? If so, what code should be used and what is the time frame before surgery to submit this code? A: If the decision for surgery occurs on the day of or day before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision making service, not the history and physical (H&P) alone. If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package. POSTOP PERIODS FOR COMMON SPINE PROCEDURES The following tables are not a complete listing of Medicare s postoperative global periods refer to a Medicare resource for other CPT codes. Also, check with your non-medicare payors to see if they follow Medicare s guidelines. 0-Day Global Period CPT Description Placement of cranial tongs Epidural steroid injection 10-Day Global Period* CPT Description Vertebroplasty Vertebral augmentation Place epidural catheter Placement of spine infusion pump Placement of epidural neurostimulator array *Note: The intent of a 10-day global period is that the first postoperative visit is included and not separately reported. Remember: Add-on codes (e.g., 69990, 20930, 22840) are not subject to a global period. 90-Day Global Period CPT Description 63xxx Laminectomy, corpectomy codes 22xxx Arthrodesis codes 4

5 Global Surgical Package CPT Says The CPT codes that represent a readily identifiable surgical procedure. AANS Says 1. Positioning the patient and stabilizing the head after arrival in the operating room. 2. Preparation of the surface area to be used for the surgical exposure, which includes removal of hair, shaving the skin and marking the area for incision. 3. Infiltration of any local anesthetic and/or vasoconstrictive agents into the part to be incised, when the procedure is performed under general anesthesia. 4. Surgical approach to the area when not otherwise covered by a separate approach procedure code (e.g., skull base approach codes ), with identification and protection of regional anatomic structures, to include hemostasis and nerve stimulation. 5. Wound management techniques including use of wound irrigation, wound cultures, and placement and removal of surgical drainage or suction devices. 6. Use of imaging techniques during the procedure, including fluoroscopy, x-rays, angiography, and ultrasonography and including supervision or direction of such techniques. (Imaging is included unless otherwise specified to code it separately.) 7. Use of special surgical adjuncts such as the laser or ultrasonic aspirating device. 8. Use of data from electronic monitoring of cerebral potentials (EEG, evoked potentials) or motor evoked potentials with intraoperative EMG. 9. Use of magnification with loupes. 10. Closure of the operative wound with repair of the operative tract. 11. Application of dressings, braces, splints or casts including traction where appropriate. 12. Takedown of the patient from operative positioning and fixation devices with transfer to a bed or gurney. AANS says basic services EXCLUDED from the global service package include: 1. Placement of additional and/or special devices preparatory to initiation of surgery, i.e., placement of a lumbar drain catheter for spinal fluid drainage during craniotomy. 2. Application of halo or other complex fixation or traction devices to the skull in the operating room if not just for operative use. 3. Placement of a twist drill or burr hole for ventricular puncture that is followed by other surgery (61105, 61120) or for implanting a ventricular catheter before surgery (61107, 61210). This is to be excluded if done in a separate location to the craniotomy (opposite side or different setting). 4. Microdissection by use of an operating microscope (69990) for intracranial or spinal procedures for structures and pathology that are so small as not easily seen without use of the microscope for dissection and illumination of dural or intradural lesions (except 22551, 22552, 61548, , 64727, and ). Code may be reported with spine procedure codes (e.g., , ). 5. Complicated wound closure requiring mobilization of scalp or skin flaps and/or skin graft (13160, 13300, , , , ). 6. Treatment for the underlying condition or an added course of treatment, which is not part of the normal recovery from surgery. 7. Clearly distinct surgical procedures during the postoperative period or staged procedures. 8. Critical care services (codes and 99292) unrelated to the surgery. Note: The American Academy of Orthopaedic Surgery (AAOS) global service guide has similar guidelines. 5

6 Principles of Spine Procedure Coding Bone Graft Allograft vs. autograft Morselized vs. structural Instrumentation Location: anterior vs. posterior vs. intervertebral Remember: There are some bundled decompression/ discectomy and fusion codes (e.g., 22551) so don t unbundle and bill separately (e.g., and 22554). Arthrodesis Approach: anterior vs. posterior vs. lateral extracavitary vs. pre-sacral Region: cervical vs. thoracic vs. lumbar Decompression (e.g., laminectomy, discectomy, corpectomy, spine fracture repair) Approach: anterior vs. posterior vs. lateral extracavitary Region: cervical vs. thoracic vs. lumbar Any other procedures performed? Examples: 1) Microdissection (+69990) 2) Stereotactic navigational planning (+61783) 3) Bone marrow aspirate (38220) through a separate needle puncture site (e.g., via iliac crest for cervical procedure) or documented separate skin/fascial incision. 6

7 Posterior Spine Instrumentation Codes: , Posterior Instrumentation: Code based on the # of attachments and # of segments spanned CPT CPT Description Code Posterior non-segmental instrumentation (e.g., Harrington rod technique), pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminal wires); 3 to 6 vertebral segments to 12 vertebral segments or more vertebral segments Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) Coding Only 2 points of attachment regardless of # of vertebral segments spanned More than 2 points of attachment. Count # of vertebral segments spanned. Use when performed alone; do not report in addition to 22840, e.g., iliac wing rods/screws/bolts; typically used in deformity correction procedures Updated in 2013: The combined arthrodesis codes and have been added to the inclusionary parenthetical notes following and 22851, indicating that and may be reported in conjunction with these codes. Examples of Instrumentation 1. L5-S1 pedicle screws and rods 2. L3-L4-L5 pedicle screws and rods 3. L3-L5 pedicle screws and rods (with nothing at L4 due to fracture) Code 4. Pedicle screws and rods at L1-2, L2-3, L3-4, L4-5, L5-S1 5. Lateral mass screws at C2-C3 *Appropriate decompression, fusion and bone graft codes may be separately reported as documented in the operative note. CPT Says: Do not append modifier 62 to spinal instrumentation codes Beware CMS payment policy still allows modifier 62! Remember: All spinal instrumentation codes are add-on codes (billed and reimbursed at 100%). 7

8 Anterior Instrumentation Codes ( ) 1 ST segment 2 ND segment 3 vertebral segments = RD segment CPT Code CPT Description Anterior instrumentation; 2 to 3 vertebral segments to 7 vertebral segments or more vertebral segments Anterior Instrumentation: Code based on the number of vertebral segments spanned. Alert: The anterior instrumentation must be a device that crosses an interspace and can provide support and stand alone in order to separately report Do not report in addition to for low profile intervertebral devices with attached plates/buttress screws or a device that cannot provide independent stabilization on its own. Intervertebral Device Code: Examples: Polyether ether ketone (PEEK), titanium, expandable cage, carbon fiber CPT Code CPT Description Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), methylmethacrylate) to vertebral defect or interspace Placement of methylmethacrylate around the pedicle screws in a patient with sever osteoporosis, to reinforce the instrumentation, is not separately reported with or any other code. This is considered part of the instrumentation code (e.g., 22840). Off-label use for insertion mesh bag filled with cement in an interspace may be reported using If percutaneously placed in the interspace, use (Unlisted procedure, spine). Use for open kyphoplasty where cement injected into vertebral body during an open procedure. 8

9 Bone Graft Codes ( ) CPT Says: Do not append modifier 62 to bone graft codes Remember: All bone graft codes are add-on codes (billed and reimbursed at 100%). CPT Description Code Allograft, morselized or placement of osteopromotive materials for spine surgery only (List separately in addition to code for primary procedure) Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) Each bone graft code may be reported once per operative session (not once per spinal interspace or per side). There is no code for reconstruction of the iliac crest defect after graft harvest this activity is included in or Off-label use for insertion mesh bag filled with morselized allograft in an interspace may be reported using Bone Marrow Aspiration CPT Description Code Bone marrow; aspiration only (For needle aspiration of bone marrow for the purpose of bone grafting, use 38220) May report when bone marrow aspirate is harvested via a separate skin or fascial incision (e.g., iliac crest). Do not report when bone marrow aspirate is harvested from the same surgical site (e.g., pedicle) Do not use a bone marrow transplant code such as

10 Laminectomy For Stenosis Codes Laminectomy for Stenosis / Spondylosis Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), one or two vertebral segments Cervical (63001), thoracic (63003), lumbar (63005) and sacral (63011) No additional level codes Primary diagnosis is stenosis May not report with modifier 50, procedure is inherently bilateral Example of 63001: Decompressive laminectomies at C2 and C3 for stenosis Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), more than 2 vertebral segments Cervical (63015), thoracic (63016) and lumbar (63017) No additional level codes Primary diagnosis is stenosis May not report with modifier 50, procedure is inherently bilateral Example of 63015: Decompressive laminectomies at C2, C3, C4 and C5 for stenosis Laminectomy, facetectomy and foraminotomy (unilateral or bilateral) with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), single vertebral segment Cervical (63045), thoracic (63046) and lumbar (63047) is the add-on code for this family of codes May not report with modifier 50, code says unilateral or bilateral Primary diagnosis is usually stenosis or spondylosis Use for revision (re-do) laminectomy when performed due to stenosis do not report Report one code per interspace/level of foraminotomy Use code for minimally invasive procedure (e.g., using tubular retractor system). Report code(s) the same as if performed via longer incision. For example, a bilateral L4-L5 procedure via two small minimally invasive incisions is one code, 63047, and not two codes. Example of 63047: L4-5 partial laminectomies, foraminotomies and partial facetectomies for stenosis ALERT: CPT Assistant, December 2012 supports the use of for procedures to address stenosis and the use of for procedures to treat disc disease. 10

11 Laminectomy For Disc Disease Laminectomy for Disc Disease ALERT: Repair of the annulus is included in the discectomy codes and not separately reported with an unlisted code such as or (CPT Assistant, December 2012). Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace. Cervical (63020) or lumbar (63030); no thoracic code is the add-on code for this family of codes May report with modifier 50, these are unilateral codes Primary diagnosis is disc disease Use code for minimally invasive procedure (e.g., using tubular retractor system). Report code(s) the same as if performed via longer incision. For example, excision of right L4-L5 and right L5-S1 discs via two small minimally invasive incisions is and (not and 63030). Do not use this series of codes for percutaneous discectomy where procedure is performed under fluoroscopy and there is no direct visualization of the anatomy look at instead. Endoscopically assisted laminotomy (hemilaminectomy) requires open and direct visualization. When visualization is only endoscopic and/or image guidance, the procedure is percutaneous and reported using 0274T, 0275T. So, be sure to document direct visualization! Includes annulus closure/repair using any sort of annulus closure device or soft tissue reinforcement do not separately report Example of 63030: Left L4-5 hemilaminectomies, foraminotomy and discectomy for herniated disc Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace These codes are used for re-exploration discectomy procedures performed at the exact same level(s) as the previous procedure when the surgeon is out of the global period for the first procedure Cervical (63040) or lumbar (63042) no thoracic codes is the add-on code for a reexploration cervical level; is the add-on code for reexploration lumbar level May report with modifier 50, these are unilateral codes Codes are valued higher to account for additional work involved with performing a re-exploration (e.g., excision of scar tissue, distorted landmarks) Includes annulus closure/repair using any sort of annulus closure device or soft tissue reinforcement do not separately report Check your local Medicare carriers and private payors for their reimbursement policies on the additional level codes (63043 and 63044). Most Medicare carriers have an allowable even though the Federal Register designates this code as carrier priced with zero RVUs Example of 63042: Reexploration left L4-5 partial laminectomies, foraminotomy and partial facetectomy for disc disease 11

12 Other Laminectomy Codes Laminectomy for Spondylolisthesis (Gill Procedure) Laminectomy with removal of abnormal facets and/or pars interarticularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) May not report with modifier 50; no add-on code Procedure is almost always done at L5-S1 for a single interspace decompression Involves laminectomy and removal of both articular facets. Typically involves a pars defect (e.g., fracture, loose lamina). Diagnosis of spondylolisthesis not disc disease, stenosis or spondylosis Transpedicular Approach, Lumbar Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (e.g., far lateral herniated intervertebral disc) is the add on code May not report bilaterally An approach to disc removal that typically includes removal of the pedicles and/or facet joints Diagnosis is typically far lateral herniated disc Not to be used for transforaminal lumbar interbody fusion (TLIF) approaches (22630) or percutaneous endoscopic discectomies (62287). Do not use just because you are doing a TLIF rather consider instead. Use for thoracic Percutaneous Laminotomy/Laminectomy 0274T 0275T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic lumbar Codes include fluoroscopy and CT imaging do not separately report 7xxxx codes Use for percutaneous decompression of the nucleus pulposus of intervertebral disc utilizing needle based technique Use for open/direct visualization approach; do not use if direct visualization is not performed and documented 12

13 Laminectomy Cases 1. Diagnosis: Lumbar stenosis Procedure: Right minimally invasive L4-L5 foraminotomy and hemilaminectomy for stenosis. 2. Diagnosis: Herniated disc Procedure: Left L2-L3 hemilaminectomy, facetectomy, discectomy and foraminotomy for with use of the operating microscope for microdissection. Repair of annulus and soft tissue reinforcement. A B L2-L3 discectomy L2-L3 discectomy Annulus repair Use of operating microscope Use of operating microscope 3. Diagnosis: L5-S1 herniated disc, L4-5 spinal stenosis Procedure: 1) Left L5-S1 hemilaminectomy, facetectomy and discectomy 2) Decompressive laminectomy with foraminotomies at L4-L5 A B Laminectomy, foraminotomy Discectomy Discectomy Additional level discectomy 4. Diagnosis: L4 and L5 stenosis Procedure: Partial L4 and L5 laminectomies and facetectomies with foraminotomy at L4-L5 for decompression of the L4 exiting nerve root and L5 traversing nerve root with use of the operating microscope for microdissection. A B Laminectomy, foraminotomy Laminectomy, foraminotomy Use of operating microscope Additional level, laminectomy Use of operating microscope 5. Diagnosis: L4-L5 herniated disc and stenosis Procedure: Left L4-L5 partial laminectomies, partial facetectomy and discectomy 6. Diagnosis: Stenosis Procedure: Decompressive L4-L5 laminectomies 13

14 Laminectomy Cases 7. Diagnosis: Lumbar stenosis Procedure: Partial inferior laminectomy L4 and complete laminectomy L5, facetectomies and L4-L5 and L5-S1 foraminotomies. 8. A. Re-do right L4-5 discectomy 6 weeks postop B. Re-do right L4-5 discectomy one year postop 9. Re-exploration laminectomies, foraminotomies, discectomies, right L4-L5 and right L5-S1 10. Re-exploration bilateral L4-5 hemilaminectomies, foraminotomies with partial facetectomies and discectomies. 11. Diagnosis: Right L4-L5 recurrent herniated disc, L3-L4 stenosis Procedure: Re-exploration laminectomies, foraminotomies and discectomy, right L4-L5 with decompressive L3-L4 laminectomy with facetectomies and foraminotomies 12. Re-exploration right laminectomy and foraminotomy at L4-5 for stenosis. A B Laminectomy, foraminotomy Re-exploration laminotomy (hemilaminectomy) 13. Diagnosis: Lumbar spinal stenosis Procedure: Minimally invasive with direct visualization right L2-L3 and right L4-L5 partial laminectomies and foraminotomies through 2 separate stab incisions. A B Laminectomy, foraminotomy Laminectomy, foraminotomy, first incision Additional level Laminectomy, foraminotomy, second incision 14

15 Posterior Fusions Cervical CPT Code Description Arthrodesis, posterior technique, craniocervical (occiput-c2) Arthrodesis, posterior technique, atlas-axis (C1-C2) Thoracic Lumbar Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment each additional segment (List separately in addition to code for primary procedure) There are no add-on codes for or If an arthrodesis is performed from the occiput to C3 then report and CPT Code Description Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) each additional segment (List separately in addition to code for primary procedure) CPT Code Description Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or lateral transverse technique, when performed) each additional segment (List separately in addition to code for primary procedure) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar each additional interspace (List separately in addition to code for primary procedure) 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 each additional interspace and segment (List separately in addition to code for primary procedure) Coding Tips: Do not report in conjunction with for the same interspace and segment, use Use in conjunction with 22600, 22610, 22612, or when performed at a different level. Tip: Report one stand-alone fusion code even when the procedure crosses spine junctional levels. Use the stand-alone fusion code for the spine region where the majority of the procedure/ levels is performed. 15

16 Posterior Fusions Can a decompressive laminectomy (i.e., 63047) code be reported with or 22633? Medicare bundles when performed with CPT considers it an accurate coding combination, if decompression above that needed for the PLIF is performed and documented. CPT Assistant, January 2001 says (paraphrased) the appropriate code(s) should be reported, when in addition to removing the disc and preparing the vertebral endplate, the surgeon removes posterior osteophytes and decompresses the spinal cord or nerve root(s), which requires work in excess of that normally performed when doing a posterior lumbar interbody fusion (PLIF). For example, in spinal procedures performed on patients having lateral lumbar stenosis, the surgeon may need to perform additional work above and beyond that described by the PLIF, including facetectomy(ies) and/or foraminotomy(ies), to adequately decompress the nerve roots. For the purpose of this example, code should be reported in addition to code APPEAL DENIALS OF WHEN BILLED WITH I am submitting an appeal for Ms. Patient s denied code As you will see on the attached claim, code is the primary procedure and code is a secondary procedure. According to the American Medical Association s Current Procedural Terminology (CPT) codebook and the American Association of Neurological Surgeons (AANS) guide, is considered separately reported when performed for decompression (please see attached copy of the CPT codebook page and the AANS guide page) in conjunction with In addition, review of Medicare CCI edits show a CCI edit exists with and and the suprascript of 1 means modifier 59 may be used to override this edit, if requirements for use of 59 are met. As you will see from the attached operative note, the highlighted areas reflect separately performed foraminotomies for decompression (63047) warranting use of modifier 59. As a result we respectfully request payment for If you have unique bundling edits in place for this code combination please send a hard copy to my attention. Thank you for your time and reconsideration. CPT Assistant, November with Question: May both code 63056, Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disk), single segment; lumbar, and code 22630, Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar, be reported for the same interspace/segment? Answer: No. To report both codes and for the same interspace/segment would represent duplicative work. For posterior (PLIF) or transforaminal (TLIF) approach lumbar interbody fusions, CPT code is used, and the dissection needed to access the disc space in these approaches is considered an incidental component of the fusion procedure. Although code includes the phrase including.discectomy to prepare interspace (other than for decompression) and code is a discectomy for decompression, the discectomy described in code is either the same or more extensive than the discectomy described in code

17 Other Procedures Pre-Sacral Interbody Fusion Placement of Posterior Instrumentation? New in 2013! YES NO L5-S T L4-L5 0195T L5-S T L4-L Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace (Do not report in conjunction with , 22840, 22848, 72275, 77002, 77003, 77011, 77012) +0309T Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure) (Use 0309T in conjunction with 22586) (Do not report 0309T in conjunction with , 22840, 22848, 72275, 77002, 77003, 77011, 77012) 0195T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace 0196T L4-L5 interspace (List separately in addition to code for primary procedure) (Do not report 0195T, 0196T in conjunction with , 22558, 22840, 22845, 22852, 72275, 76000, 76380, 76496, 76497, 77002, 77003, 77011, 77012) 17

18 Other Procedures Facet Wedge or Dowel Fusion (Intrafacet Implant) Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level Cervical: 0219T Thoracic: 0220T Lumbar: 0221T Additional level: +0222T Includes fluoroscopy and any radiological service Includes bone graft, instrumentation and fusion do not report 0219T-0221T with , , , , at the same level. Posterior Spinous Process Distraction Device 0171T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level +0172T each additional level (List separately in addition to code for primary procedure) Also called interspinous process implant May report with decompression code (e.g., 63047) Example: Intraspinous process fusion L5-S1, left L5 partial laminectomy Description of Procedure:..incision was made in the midline fascia was split midline over the spinous processes. attention was turned to the left side where partial laminectomy was performed. Next, the distraction device was placed over the spinous process and used to distract the L5-S1 joint and x-ray identified adequate distraction with a size 10 implant. Once this was confirmed, actual size 10 implant was put in place. X-ray confirmed placement of the intraspinous process device. Then plate was measured and size 4 to 5 was an adequate fit. It was placed between the spinous processes of L5-S1 without difficulty and excess midline bulk was cut and removed. X-ray fluoroscopy was then used to take final pictures and device was found to be in adequate location on both AP and lateral views. The wound was irrigated. Astramorph was injected into the dural space. The lumbar fascia was closed, skin and subcutaneous tissues were closed with sutures followed by Dermabond, 4x4s, Steri-strips and Tegaderm. 18

19 Other Procedures (continued from previous page) A B Posterior fusion, first level 0171T Insertion of posterior spinous process distraction device Non-segmental instrumentation RT Lumbar discectomy, first level LT Additional level Injection of Astramorph Posterior Spinous Process Fixation Device Unlisted procedure, spine Also called interspinous process clamp Example: Interlaminar lumbar fusion with spinous process fixation device May report with decompression code (e.g., 63047), arthrodesis (e.g., 22612) and/or bone graft (e.g., 20936) Do not use or Example Interlaminar lumbar instrumented fusion including distraction of space between the spinous processes, removal of small sections of bone to relieve pressure on the spinal cord and nerves, and placement of a precision-machined allograft bone between the spinous processes for permanent distraction and fixation. A small plate is then attached to both spinous processes to stabilize the segment and promote fusion A B Posterior fusion, first level Posterolateral fusion, first level Spinous process wiring Unlisted procedure, spine Structural allograft Structural allograft Percutaneous Sacroiliac Joint Stabilization Unlisted procedure, spine Minimally invasive S-I joint fusion performed percutaneously for degenerative disease Accepted Category II code 0301XT to report percutaneous stabilization of the sacroiliac joint (SIJ), but currently being appealed with request received by AMA to delay publication of this Category III code. Use (unlisted procedure, spine) until Category III code issue resolved 19

20 Posterior Fusion Cases Case #1 1. L4-5 posterolateral fusion with pedicle screws and rods, local bone 2. L4-5 laminectomies, foraminotomies and partial facetectomies to decompress the nerve roots Case #2 1. L5-S1 Laminectomy and discectomy 2. TLIF L5-S1 with PEEK device and BMP 3 L5-S1 pedicle screw and rod placement Case #3 1. L5-S1 partial laminectomies, facetectomies and foraminotomies for decompression of the nerve roots. 2. L5-S1 TLIF with placement of PEEK device and morselized allograft 3. L5-S1 posterior fusion with pedicle screws and rods and local bone. A B Combined posterior fusion and interbody fusion Combined posterior fusion and interbody fusion Decompression Transpedicular decompression Instrumentation Instrumentation PEEK device PEEK device Morselized allograft Morselized allograft Local bone Local bone Case #4 1. L5-S1 discectomy and TLIF with placement of PEEK cage and local autograft. 2. L5-S1 posterior fusion with pedicle screws and rods and local bone graft. 20

21 Exploration of Fusion and Hardware Removal/Reinsertion Codes CPT Guideline Codes 22849, 22850, 22852, and are subject to modifier 51 if reported with other definitive procedure(s), including arthrodesis, decompression, and exploration of fusion. Code should not be reported in conjunction with 22850, 22852, and at the same spinal levels. Only the appropriate insertion code ( ) should be reported when previously placed spinal instrumentation is being removed or revised during the same session where new instrumentation is inserted at levels including all or part of the previously instrumented segments. Do not report the reinsertion (22849) or removal (22850, 22852, 22855) procedures in addition to the insertion of the new instrumentation ( ). CPT Code Description Exploration of spinal fusion Reinsertion of spinal fixation device Removal of posterior nonsegmental instrumentation (e.g., Harrington rod) Removal of posterior segmental instrumentation Removal of anterior instrumentation ALERT There is no code for removal of an intervertebral device this would be part of an exploration of fusion. Do not use (removal of implant) for removing spine instrumentation. 21

22 Exploration of Fusion and Hardware Removal/Reinsertion Codes 1. Purpose of operation is to extend a solid fusion to an adjacent level. Example: Removal of C6-C7 plate to perform a C5-C6 ACDF. Recommendation: Do not report (exploration) for the solid fusion level. Do not report instrumentation removal code (e.g., 22850, 22852, 22855). Report the appropriate fusion code and the appropriate code for the length of the new instrumentation. Teaching Point: No exploration is needed for a solid fusion and given the significant overlap in physician work so code for the new instrumentation placed. Remember, CPT says not to report a removal code in addition to an insertion code. 2. Purpose of the operation is to explore a fusion because pseudoarthrosis is suspected - no extension of the fusion. Recommendation: Report (exploration) of the level with pseudoarthrosis (report code once per operation). Report re-insertion of instrumentation (because removal and replacement was at exact same level(s) 22849). Do not report a new instrumentation code (e.g., 22842). Report fusion code (e.g , 22554). 3. Purpose of operation is to explore a fusion because pseudoarthrosis is suspected - there WILL be extension of the fusion. Example: Removal of L5-S1 rods (and screws, when performed) with L4-L5 fusion and placement of pedicle screws at L4-L5 and new rods at L4-S1. Recommendation: Report (exploration) Report new instrumentation code for entire length of new construct (e.g., 22842) Report fusion code (e.g ) Teaching Point: Do not code instrumentation removal (22850, 22852, 22855) unless it was at a non-adjacent level(s) due to the overlap in work. 22

23 Anterior Cervical Decompression/Fusion Anterior Cervical Arthrodesis/Fusion Anterior Cervical Decompression CPT Code Description Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C each additional interspace (list separately in addition to code for primary procedure) CPT Code Description Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), inclduing osteophytectomy; cervical, single interspace each additional interspace (list separately in addition to code for primary procedure) When performed together at the same level(s), report: Anterior Cervical Discectomy/Decompression and Fusion CPT Code Description Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophyectomy and decompression of spinal cord and/or nerve roots; cervical below C cervical below C2, each additional interspace (list separately in addition to code for separate procedure) Tips: Do not bill in conjunction with 63075, even if performed by a separate individual. Codes and include (do not separately report with or 22552). CPT also includes Use when performed with codes other than (e.g., corpectomy). Use when performed with code other than

24 ACDF Cases Anterior Cervical Discectomy/Decompression and Fusion Examples Number of Levels One (e.g., C5-C6) Two (e.g., C5-C6, C6-C7) Three (e.g., C4-C5, C5-C6, C6-C7) With Structural Allograft and Anterior Plate (ACDF) (Plate) (Allograft) (Add. Level) OR x 2 units With PEEK Device, Separate Anterior Plate, and Morselized Allograft (PEEK device) (Allograft) OR x 2 units OR x 2 units x 3 units With Combined PEEK Device/Screws/Plate and Morselized Allograft OR x 2 units OR x 2 units x 3 units Note: May substitute/add other bone graft(s) as appropriate (e.g., , ) 24

25 ACDF Case 1. Non-adjacent two level fusion (e.g., C4-C5 and C6-C7) anterior cervical discectomies and fusion with PEEK intervertebral devices, placement of morselized allograft in the PEEK device, and two separate anterior plates that are placed at C4-C5 as well as at C6-C7. A ACDF ACDF ACDF, second level Additional level Anterior instrumentation Anterior instrumentation Anterior instrumentation Anterior instrumentation Intervertebral device Intervertebral device Intervertebral device Intervertebral device Morselized allograft Morselized allograft 2. Procedure: 1) C4-C5 anterior cervical discectomy/decompression of spinal cord and nerves 2) Arthrodesis with placement of PEEK intervertebral device, plate with allograft and autograft Surgeon: Dr. Unbundler Co-Surgeon: Dr. Partner A Partial corpectomy, first level ACDF Partial corpectomy, second level Anterior instrumentation , 59 Anterior cervical discectomy Intervertebral device Anterior instrumentation Morselized allograft Intervertebral device Morselized autograft , 59 Anterior cervical fusion Anterior cervical fusion , 59 ACDF Neuroplasty , 62 Neuroplasty Osteotomy, cervical Additional level osteotomy Cervical fracture repair Morselized allograft Morselized autograft Fluoroscopy Fluoroscopy Intraoperative monitoring Neuromuscular junction test Use of operating microscope Neuromuscular junction test B B 25

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