Clinical Coverage Policy No: 1A-30 Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligible Recipients... 2 2.1 General Provisions... 2 2.2 EPSDT Special Provision: Exception to Policy Limitations for Recipients under 21 Years of Age... 3 2.3 Health Choice Special Provision: Exceptions to Policy Limitations for Health Choice Recipients ages 6 through 18 years of age... 4 3.0 When the Procedure, Product, or Service Is Covered... 4 3.1 General Criteria... 4 3.2 Specific Criteria... 4 4.0 When the Procedure, Product, or Service Is Not Covered... 7 4.1 General Criteria... 7 4.2 Specific Criteria... 7 4.3 NCHC Exclusions... 7 4.4 Medicaid Exclusions... 7 5.0 Requirements for and Limitations on Coverage... 8 5.1 Prior Approval... 8 5.2 Prior Approval Requirements... 8 6.0 Providers Eligible to Bill for the Procedure, Product, or Service... 8 7.0 Additional Requirements... 8 7.1 Compliance... 8 8.0 Policy Implementation/Revision Information... 9 Attachment A: Claims-Related Information... 10 A. Claim Type... 10 B. Diagnosis Codes... 10 C. Billing Code(s)... 10 D. Modifiers... 17 E. Billing Units... 17 F. Place of Service... 17 G. Co-payments... 17 H. Reimbursement... 17 03.22.2012 45-Day Comment i
Clinical Coverage Policy No: 1A-30 1.0 Description of the Procedure, Product, or Service There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital/developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spinal problem, or whether it is caused by some other body system (kidney disorder, aortic aneurysm, etc.) mimicking back pain. Most conditions affecting the spine are self-limited, and improve or completely resolve with conservative treatments such as: rest or activity reduction, oral medications, topical (ice packs, heat, ointments, etc.), orthotics (back brace, corset, etc.), physical therapy, chiropractic manipulation, facet joint injections, or epidural steroid injections. Spinal injections and surgical treatments are only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (fractures, cancer, etc.) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord and/or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion surgery of the back is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spine instability, cord compression due to severe slipped discs or arthritis, fractures in the spine or destruction of the vertebrae by infection or tumor. Spinal instability means increased motion of the vertebra over one another to the point that the spinal cord or nerve roots may be compressed. 1.1 Definitions Artificial discs. Implanted artificial discs are a treatment alternative to spinal fusion for painful movement between two vertebrae due to a degenerated or injured disc. These relatively new devices are still being studied, however, so it's not yet clear what role they might play as a back surgery option. Cauda equina syndrome (CES) is a condition caused by compression of multiple lumbosacral nerve roots in the spinal canal due to an abrupt prolapse of the lumbar disc. Clinical CES is a medical emergency characterized by bilateral sciatica in the lower back and upper buttocks, saddle anesthesia, urinary retention, bowel dysfunction. CPT codes, descriptors, and other data only are copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 03.22.2012 45-Day Comment 1
Conservative Therapy Treatment options include physical therapy, hot and cold packs, back exercises, weight reduction, steroid injections (epidural steroids), nonsteroidal antiinflammatory medications, rehabilitation and limited activity. Discectomy. This involves removal of the herniated portion of a disc to relieve irritation and inflammation of a nerve. It's done as an open surgery and typically involves full or partial removal of the back portion of a vertebra (lamina) to access the ruptured disc. Fusion. Spinal fusion permanently connects two or more bones in the spine. It can relieve pain by adding stability to a spinal fracture. It is occasionally used to eliminate painful motion between vertebrae that can result from a degenerated or injured disc. Herniated disc is a rupture of fibrocartilagenous material (annulus fibrosis) that surrounds the intervertebral disc. Laminectomy. This procedure involves the removal of the bone overlying the spinal canal. It enlarges the spinal canal and is performed to relieve nerve pressure caused by spinal stenosis. The Meyerding Grading System is used to classify the degree of vertebral slip forward over the vertebral body beneath: Grade 1 1-24% of vertebral body has slipped forward Grade 2 25% to 49% Grade 3 50% to 74% Grade 4 75% to 99% Grade 5 Complete slip (100%), known as spondyloptosis) Radiculopathy is any disease of the spinal nerve roots and spinal nerves. It is characterized by pain which seems to radiate from the spine to extend outward to cause symptoms away from the source of the spinal nerve root irritation. Spondylolisthesis describes the forward slippage of one vertebral body with respect to the one beneath it. Vertebroplasty. During this procedure, the surgeon injects bone cement into compressed vertebrae. For fractured and compressed vertebrae, this procedure can help stabilize fractures and relieve pain. With a similar but more expensive procedure called kyphoplasty a balloon-like device is inserted to attempt to expand compressed vertebrae before bone cement is injected. 2.0 Eligible Recipients 2.1 General Provisions NC Medicaid (Medicaid) recipients must be enrolled on the date of service and may have service restrictions due to their eligibility category that would make them ineligible for this service. 03.22.2012 45-Day Comment 2
NC Health Choice (NCHC) recipients, ages 6 through 18 years of age, must be enrolled on the date of service to be eligible, and must meet policy coverage criteria, unless otherwise specified. 2.2 EPSDT Special Provision: Exception to Policy Limitations for Recipients under 21 Years of Age 42 U.S.C. 1396d(r) [1905(r) of the Social Security Act] Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination** (includes any evaluation by a physician or other licensed clinician). This means EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Medically necessary services will be provided in the most economic mode, as long as the treatment made available is similarly efficacious to the service requested by the recipient s physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient s right to a free choice of providers. EPSDT does not require the state Medicaid agency to provide any service, product, or procedure a. that is unsafe, ineffective, or experimental/investigational. b. that is not medical in nature or not generally recognized as an accepted method of medical practice or treatment. Service limitations on scope, amount, duration, frequency, location of service, and/or other specific criteria described in clinical coverage policies may be exceeded or may not apply as long as the provider s documentation shows that the requested service is medically necessary to correct or ameliorate a defect, physical or mental illness, or a condition [health problem]; that is, provider documentation shows how the service, product, or procedure meets all EPSDT criteria, including to correct or improve or maintain the recipient s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. **EPSDT and Prior Approval Requirements a. If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does NOT eliminate the requirement for prior approval. b. IMPORTANT ADDITIONAL INFORMATION about EPSDT and prior approval is found in the Basic Medicaid Billing Guide, sections 2 and 6, and on the EPSDT provider page. The Web addresses are specified below. Basic Medicaid Billing Guide: http://www.ncdhhs.gov/dma/basicmed/ EPSDT provider page: http://www.ncdhhs.gov/dma/epsdt/ 03.22.2012 45-Day Comment 3
2.3 Health Choice Special Provision: Exceptions to Policy Limitations for Health Choice Recipients ages 6 through 18 years of age EPSDT does not apply to NCHC recipients. If a NCHC recipient does not meet the clinical coverage criteria within Section 3.0 of the clinical coverage policy, the NCHC recipient will be denied services. Only services included under the Health Choice State Plan and the DMA clinical coverage policies, service definitions, or billing codes will be covered for NCHC recipients. 3.0 When the Procedure, Product, or Service Is Covered Note: Refer to Subsection 2.2 regarding EPSDT Exception to Policy Limitations for Medicaid Recipients under 21 Years of Age. 3.1 General Criteria Procedures, products, and services related to this policy are covered when they are medically necessary and a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient s needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the recipient, the recipient s caretaker, or the provider. 3.2 Specific Criteria a. Medicaid and NCHC considers lumbar laminectomy medically necessary for recipients with a herniated disc when all of the following criteria are met: 1. Another source of the pain has not been determined; 2. Imaging studies (e.g., computed tomography (CT) or magnetic resonance imaging (MRI)) indicate nerve root compression that corresponds to the clinical findings of the specific affected nerve root; 3. Recipient has failed at least 6 weeks of conservative therapy ; 4. Recipient's activities of daily living are limited by persistent pain radiating from the back down to the lower extremity; 5. Physical findings of nerve root tension are present (e.g., positive straight leg raising); and 6. Presence of neurological abnormalities (e.g., reflex change, sensory loss, weakness) or unremitting pain, despite conservative care, persist on examination and correspond to the specific affected nerve root. 03.22.2012 45-Day Comment 4
b. Medicaid and NCHC considers cervical laminectomy, cervical laminoplasty or cervical decompression (may be combined with an anterior approach) medically necessary for recipients with a herniated disc when all of the following criteria are met: 1. Another source of the pain has not been determined; 2. History of neck pain with radicular pain to the upper extremity, weakness, and sensory disturbance; 3. Imaging studies (e.g., CT or MRI) indicate disc herniation or severe foraminal stenosis at the level corresponding with the clinical findings; 4. Recipient has failed at least 6 weeks of conservative therapy (unless there is evidence of cervical cord compression, which requires urgent intervention); 5. Recipient's activities of daily living are limited by persistent neck and radicular pain. c. Medicaid and NCHC considers lumbar decompression with or without discectomy medically necessary for cauda equina syndrome (symptoms include bilateral lower extremity weakness, numbness or decreased sensation, saddle anesthesia, bladder and bowel dysfunction) confirmed by imaging studies (e.g., CT or MRI). d. Medicaid and NCHC considers cervical, lumbar or thoracic decompressive procedures (laminectomy, discectomy, laminotomy, foraminectomy, foraminotomy, or a foraminolaminectomy) medically necessary for any of the following: 1. Evidence of cervical myelopathy confirmed by imaging studies (e.g., (CT) scan or (MRI)) with corresponding clinical signs and symptoms (including, but may not be limited to, bowel or bladder incontinence, clumsiness of hands, frequent falls, hyperreflexia, Hoffman sign, increased tone or spasticity, urinary urgency); 2. Rapidly progressive neurologic signs/symptoms of lumbar spine compression confirmed by imaging studies (e.g., CT scan or MRI); 3. Spinal fracture, dislocation (associated with mechanical instability), locked facets, or displaced fracture fragment confirmed by imaging studies (e.g., CT or MRI); 4. Spinal infection confirmed by imaging studies (e.g., CT or MRI); 5. Spinal tumor confirmed by imaging studies (e.g., CT or MRI); 6. Herniated disc or spinal stenosis at the level corresponding with clinical findings confirmed by imaging studies (e.g., magnetic resonance imaging (MRI) or myelogram); 7. Physical and neurological abnormalities suggestive of nerve root or spinal cord compression (e.g., weakness, sensory loss, reflex change); or 8. Radicular back pain that has persisted despite appropriate conservative treatment (e.g., rest, medications, physical therapy, etc.). 03.22.2012 45-Day Comment 5
e. Medicaid and NCHC considers corpectomy for spinal cord or nerve root compression medically necessary for vertebral fractures or tumors in the cervical, thoracic or lumbar regions or severe degenerative disease requiring decompression of the spinal cord with complicated underlying conditions such as ossification of the posterior longitudinal ligament (OPLL). f. Medicaid and NCHC considers lumbar spinal fusion medically necessary for any of the following: 1. Severe degenerative scoliosis, kyphosis, or pseudoarthrosis (non-union of prior fusion), which is associated with radiological (e.g., CT or MRI) evidence of mechanical instability or deformity of the lumbar spine with progression of deformity to greater than 50 degrees with loss of function that has failed 3 months of conservative management; 2. Spinal fracture, dislocation (associated with mechanical instability) confirmed by imaging studies (e.g., CT or MRI), which may be combined with a laminectomy; 3. Spinal infection confirmed by imaging studies (e.g., CT or MRI) and/or other studies (e.g., biopsy), which may be combined with a laminectomy; 4. Spinal tumor confirmed by imaging studies (e.g., CT or MRI), which may be combined with a laminectomy; 5. Isthmic, congenital, post-traumatic spondylolisthesis with segmental instability confirmed by imaging studies (e.g., CT or MRI), when both of the following criteria are met: A. Spondylolisthesis, Grade I, II, III, IV, or V (Refer to Subsection 1.1 definitions) and B. Symptomatic unremitting pain that has failed three months of conservative management; or 6. Spinal stenosis with unremitting pain confirmed by imaging studies (e.g., CT or MRI) that has failed three months of conservative management when any of the following is met: A. Decompression is performed in an area of segmental instability as manifested by gross movement on flexion-extension radiographs of 4mm or greater; B. Decompression coincides with an area of degenerative instability (e.g., (severe scoliosis or clinically significant spondylolisthesis); or C. Decompression creates an iatrogenic instability by the disruption of the posterior elements where facet joint excision exceed 50% bilaterally or complete excision of one facet is performed. g. Medicaid considers spinal surgery in persons with prior spinal surgery medically necessary when any of the above criteria is met. Note: If imaging studies indicate only fibrosis or scar tissue, surgery is not indicated. 03.22.2012 45-Day Comment 6
4.0 When the Procedure, Product, or Service Is Not Covered Note: Refer to Subsection 2.2 regarding EPSDT Exception to Policy Limitations for Medicaid Recipients under 21 Years of Age. 4.1 General Criteria Procedures, products, and services related to this policy are not covered when a. the recipient does not meet the eligibility requirements listed in Section 2.0; b. the recipient does not meet the medical necessity criteria listed in Section 3.0; c. the procedure, product, or service unnecessarily duplicates another provider s procedure, product, or service; or d. the procedure, product, or service is experimental, investigational, or part of a clinical trial. Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges, health benefits coverage provided to children eligible under the Health Choice program shall be equivalent to coverage provided for dependents under the NC Medicaid Program except for the following: a. No services for long-term care; b. No non-emergency medical transportation; c. No EPSDT; and d. Dental services shall be provided on a restricted basis. 4.2 Specific Criteria Other service exclusions or limitations may apply. Refer to A Consumer s Guide to North Carolina Health Care Coverage Programs for Families and Children: North Carolina Health Choice and Medicaid. Medicaid and NCHC consider: a. lumbar spinal fusion not medically necessary for degenerative disc disease and all other indications not listed in Subsection 3.2 above as medically necessary because of insufficient evidence of its effectiveness for these indications. b. cervical fusion for the treatment of axial neck pain and degenerative disks not medically necessary because of questionable and insufficient evidence of its effectiveness c. total disc arthroplasty experimental and investigational. d. laser laminectomy and any percutaneous laminectomy, laminotomy, foraminectomy, foraminotomy, foraminolaminectomy, laminoplasty, or corpectomy, experimental and investigational. 4.3 NCHC Exclusions Not Applicable 4.4 Medicaid Exclusions Not Applicable 03.22.2012 45-Day Comment 7
5.0 Requirements for and Limitations on Coverage Note: Refer to Subsection 2.2 regarding EPSDT Exception to Policy Limitations for Medicaid Recipients under 21 Years of Age. 5.1 Prior Approval Prior approval is required for most spinal surgical procedures. (refer to Attachment A) Refer to the Basic Medicaid Billing Guide, Section 6 (Prior Approval). The Billing Guide is located at http://www.ncdhhs.gov/dma/basicmed/. 5.2 Prior Approval Requirements The provider(s) shall submit to DMA s designee the following: a. the prior approval request; and b. all health care records and any other documentation to support that the recipient has met the specific criteria in Subsection 3.2 of this policy. c. if the Medicaid recipient is under 21 years of age, information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. 6.0 Providers Eligible to Bill for the Procedure, Product, or Service To be eligible to bill for procedures, products, and services related to this policy, providers shall a. meet Medicaid or NCHC qualifications for participation; b. be currently Medicaid - enrolled; and c. bill only for procedures, products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity. 7.0 Additional Requirements Note: Refer to Subsection 2.2 regarding EPSDT Exception to Policy Limitations for Medicaid Recipients under 21 Years of Age. 7.1 Compliance Providers shall comply with all applicable federal, state, and local laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) and record retention requirements. 03.22.2012 45-Day Comment 8
8.0 Policy Implementation/Revision Information Original Effective Date: January 1, 1974 Revision Information: Date Section Revised Change Throughout Initial promulgation of prior approval for current coverage of NC Medicaid and NC Health Choice Programs. 03.22.2012 45-Day Comment 9
Attachment A: Claims-Related Information Reimbursement requires compliance with all Medicaid or NCHC guidelines, including obtaining appropriate referrals for recipients enrolled in the Medicaid and NCHC managed care programs. A. Claim Type Professional (CMS-1500/837P transaction) Institutional (UB-04/837I transaction) B. Diagnosis Codes Providers shall bill the ICD-9-CM diagnosis codes(s) to the highest level of specificity that supports medical necessity. C. Billing Code(s) Providers are required to select the most specific billing code that accurately describes the service(s CPT Description Code(s) 22532 arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic 22533 arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar +22534 arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (list separately in addition to code for primary procedure) 22548 arthrodesis, anterior transoral or extraoral technique, clivus-c1-c2 (atlas-axis), with or without excision odontoid process 22551 arthrodesis, anterior interbody including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 +22552 arthrodesis, anterior interbody including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots;cervical below C2 each additional interspace (list separately in addition to code for separate procedure) 22554 arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 22556 arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic arthrodesis, anterior interbody technique, including minimal discectomy to prepare 22558 interspace (other than for decompression); lumbar arthrodesis, anterior interbody technique, including minimal discectomy to prepare +22585 interspace (other than for decompression); each additional interspace (list separately in addition to code for primary procedure) 22590 arthrodesis, posterior technique, craniocervical (occiput-c2) 22595 arthrodesis, posterior technique, atlas-axis (C1-C2) arthrodesis, posterior or posterolateral technique, single level; cervical below C2 22600 segment 22610 arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without 03.22.2012 45-Day Comment 10
CPT Code(s) Description lateral transverse technique) 22612 arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) +22614 arthrodesis, posterior or posterolateral technique; each additional vertebral segment (list separately in addition to code for primary procedure) 22630 arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to 22632 prepare interspace (other than for decompression), single interspace; each additional interspace (list separately in addition to code for primary procedure) 22800 arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments 22802 arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments 22804 arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments 22808 arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments 22810 arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments 22812 arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments 22818 kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments 22819 kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments 22830 exploration of spinal fusion +22840 +22841 +22842 +22843 +22844 +22845 +22846 +22847 posterior non-segmental instrumentation (eg, harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at c1, facet screw fixation) (list separately in addition to code for primary procedure) internal spinal fixation by wiring of spinous processes (list separately in addition to code for primary procedure) posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (list separately in addition to code for primary procedure) posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (list separately in addition to code for primary procedure) posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (list separately in addition to code for primary procedure) anterior instrumentation; 2 to 3 vertebral segments (list separately in addition to code for primary procedure) anterior instrumentation; 4 to 7 vertebral segments (list separately in addition to code for primary procedure) anterior instrumentation; 8 or more vertebral segments (list separately in addition to code for primary procedure) 03.22.2012 45-Day Comment 11
CPT Code(s) +22848 +22851 Description pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (list separately in addition to code for primary procedure) application of intervertebral mechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (list separately in addition to code for primary procedure) 63001 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (eg, spinal stenosis), one or two vertebral segments; cervical 63003 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (eg, spinal stenosis), one or two vertebral segments; thoracic 63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (eg, spinal stenosis), one or two vertebral segments; lumbar, except for spondylolisthesis 63011 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (eg, spinal stenosis), one or two vertebral segments; sacral 63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 63015 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (eg, spinal stenosis), more than 2 vertebral segments; cervical 63016 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (eg, spinal stenosis), more than 2 vertebral segments; thoracic 63017 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, (eg, spinal stenosis), more than 2 vertebral segments; lumbar 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, cervical 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar + 63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) 63040 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical 63042 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar + 63043 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, 03.22.2012 45-Day Comment 12
CPT Code(s) Description reexploration, each additional cervical interspace (List separately in addition to code for primary procedure) + 63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, each additional lumbar interspace (List separately in addition to code for primary procedure) 63045 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; cervical 63046 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; thoracic 63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; lumbar + 63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) 63055 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic 63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) + 63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure) 63064 Costovertebral approach with decompression of spinal cord or nerve root(s), (eg, herniated intervertebral disk), thoracic; single segment +63066 Costovertebral approach with decompression of spinal cord or nerve root(s), (eg, herniated intervertebral disk), thoracic; each additional segment (List separately in addition to code for primary procedure) 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace +63076 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure) 63077 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace +63078 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary procedure) 63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment +63082 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure) 03.22.2012 45-Day Comment 13
CPT Description Code(s) 63085 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment +63086 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List separately in addition to code for primary procedure) 63087 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment +63088 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure) 63090 Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment +63091 Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure) 63101 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (e.g., for tumor or retropulsed bone fragments); thoracic, single segment 63102 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (e.g., for tumor or retropulsed bone fragments); lumbar, single segment +63103 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (e.g., for tumor or retropulsed bone fragments); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure) 63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar 63172 Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space 63173 Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space to peritoneal or pleural space 63180 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments 63182 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments 63185 Laminectomy with rhizotomy; 1 or 2 segments 63190 Laminectomy with rhizotomy; more than 2 segments 63191 Laminectomy with section of spinal accessory nerve 63194 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; cervical 63195 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; thoracic 63196 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; cervical 63197 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; thoracic 03.22.2012 45-Day Comment 14
CPT Description Code(s) 63198 Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 days; cervical 63199 Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 days; thoracic 63200 Laminectomy, with release of tethered spinal cord, lumbar 63250 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical 63251 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic 63252 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar 63265 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical 63266 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic 63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar 63268 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral 63270 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical 63271 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic 63272 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar 63273 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral 63275 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical 63276 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, thoracic 63277 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar 63278 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, sacral 63280 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical 63281 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, thoracic 63282 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar 63283 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, sacral 63285 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical 63286 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic 63287 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar 63290 Laminectomy for biopsy/excision of intraspinal neoplasm; combined extraduralintradural lesion, any level +63295 Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure) 63300 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical 03.22.2012 45-Day Comment 15
CPT Description Code(s) 63301 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 63302 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach 63303 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach 63304 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical 63305 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach 63306 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach 63307 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach +63308 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment) ICD-9 Procedure Code(s) The following procedures require prior approval: Code Description 03.02 Reopening of laminectomy site 03.09 Other exploration and decompression of spinal canal 03.4 Excision or destruction of lesion of spinal cord or spinal meninges 77.89 Other partial ostectomy of other bone, except facial bones 80.51 Excision of intervertebral disc 80.59 Other destruction of intervertebral disc 80.99 Other excision of joint of other specified site The following Procedure codes do not require Prior Approval: Code Description 22852 Removal of posterior segmental instrumentation 22855 Removal of anterior instrumentation 22864 removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical 22865 removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar Revenue Codes: Revenue Description Codes 0272 Medical/Surgical supplies & devices, sterile supply 0360 Operating Room Services - General Classification 03.22.2012 45-Day Comment 16
D. Modifiers Providers are required to follow applicable modifier guidelines. E. Billing Units The appropriate procedure code(s) used determines the billing unit(s). F. Place of Service Hospital, Office; Ambulatory Surgery Centers. G. Co-payments Co-payments are not required for spinal surgery. H. Reimbursement Providers shall bill their usual and customary charges. 03.22.2012 45-Day Comment 17