North American Spine Society CODING UPDATE 2017 · 1 North American Spine Society CODING UPDATE 2017 22000 Codes Musculoskeletal Section Gregory J. Przybylski, MD 22000 Series I&D

1

North American Spine Society CODING UPDATE 2017

22000 Codes

Musculoskeletal Section

Gregory J. Przybylski, MD

22000 Series

I&D

Excision of Bony Lesions

Osteotomies

Fractures of the Spine

Vertebroplasty/ Kyphoplasty

Arthrodesis

Disc Arthroplasty

Spine Codes

Incision

22010- 22015

(work must be done below fascia)

2

Incision and Drainage Codes

22010 Incision and Drainage, open, of deep abscess, subfascial, posterior spine cervical, thoracic or cervicothoracic

22015Incision and Drainage, open, of deep abscess, subfascial, posterior spine lumbar, sacral or lumbosacral

Do not report with Removal of instrumentation codes 22850, 22852

Do not report with other I and D codes 10140, 10160, 10180

Spine Codes

Bone Excision

22100 - 22226

Excision Posterior Elements

Non Biopsy22100

Partial excision posterior vertebral component for intrinsic bony lesion Cervical

22101 Thoracic

22102 Lumbar

22103 additional segment

Not for decompression, not for biopsy, not for corpectomy

Osteoid Osteoma

Osteomyelitis

3

Excision Vertebral Body (Anterior) Non Biopsy

22110 CervicalPartial excision Vertebral body for intrinsic bony lesion

22112 Thoracic

22114 Lumbar

22116 additional level

Not for decompression, not for biopsy, not for corpectomy

Excision cervical osteophyte

Osteomyelitis

Osteotomy(fixed deformities)

3 column model

4

Osteotomy Posterior (Three Column)22206

Osteotomy posterior three

columns, thoracic, e.g. pedicle

subtraction

22207

Lumbar

22208

Each additional level

Includes all bony/ soft tissue

decompression

Osteotomy – Posterior Column

22210 Posterior cervical

22212 Thoracic

22214 Lumbar

22216 Additional segment

Osteotomy – Anterior

22220 Cervical

22222 Thoracic

22224 Lumbar


5

Spine Fracture Codes

Fracture

22305 - 22328

Fracture – Closed Treatment

22305

Closed treatment Vertebral process

fractures, Spinous process &

Transverse process

22310

Closed treatment, bracing/cast - No

manipulation

22315

Closed treatment bracing/cast - with

manipulation

Fracture – Open Treatment Anterior

22318

Open treatment odontoid

INCLUDING internal fixation,

no grafting

22319

Open treatment odontoid

INCLUDING internal fixation,

with grafting

Only two codes here

6

Fracture – Open Treatment Anterior

No specific fracture treatment codesCervical below C2

Thoracic

Lumbar

Corpectomy codes

Discectomy codes

Fusion codes

Instrumentation codes

Fracture: Open Treatment

Posterior22325

Lumbar

Open treatment/reduction posterior one vertebrae or segment

22326 Cervical

22327 Thoracic


Jumped facets, Fracture/ Dislocation

Will still code for arthrodesis and instrumentation

All above NOT for use with Vertebroplasty or Kyphoplasty

Manipulation

22505

Manipulation of spine requiring anesthesia any

region

7

Vertebroplasty

22510

Percutaneous vertebroplasty(bone biopsy included when

performed), 1 vertebral body,

unilateral or bilateral injection;

including all image guidance;

cervicothoracic

22511 lumbosacral


Replaces 22520-22522

Kyphoplasty

22513

Percutaneous Vertebral

augmentation, including cavity creation

(fracture reduction and bone biopsy

included) using mechanical device,

unilateral or bilateral , including all

image guidance – thoracic

22514 lumbar


Replaces 22523-22525

*

Vertebroplasty/ Kyphoplasty

In other words:

It is not appropriate to code for

Bone biopsy

Radiologic Supervision

Fracture treatment

Sacroplasty: Cat. III codes 0200T and

0201T

8

Percutaneous Intradiscal

Electrothermal Annuloplasty

(IDET)22526

Percutaneous intradiscal electrothermal

annuloplasty, unilateral or bilateral including

fluoroscopic guidance.

22527

One or more additional levels

CMS issued NCD (noncoverage decision)

effective January 5, 2009

Arthrodesis Codes

22532 - 22812

Arthrodesis

Anterior

Direct lateral

Pre-sacral

Posterior or Posterior lateral

Trans pedicular/ Costotransversectomy

Far lateral/ Extracavitary

MUST LOOK AT OPERATIVE REPORT

CAREFULLY – EASILY CONFUSED

DUE TO ALL NEW “MINIMAL

ACCESS” APPROACHES

9

Arthrodesis (Posterior) Lateral

Extracavitary22532

Arthrodesis lateral extracavitary

approach, thoracic (includes

minimal discectomy)

22533 Lumbar

22534 Additional level

See 63101-63103 for decompression

Arthrodesis – Anterior

22548Anterior (above C2)

(Transoral technique C1-2….with or without excision of odontoid process)

22554 Cervical (below C2)

22556 Thoracic

22558 Lumbar


No decompression…discectomy strictly for fusion

Arthrodesis - Anterior(Including Decompression)

22551

Arthrodesis, anterior interbody,

including disc space

preparation, discectomy ,

osteophytectomy and

decompression of spinal cord

and/or nerve roots; cervical

22552

Cervical below C2, each additional

interspace

10

XLIF / DLIF

Direct lateral approach

Dissection thru Obliques/

Transversus Abdominus muscles

Code exactly like an ALIF

22558

Arthrodesis (Pre-Sacral) Approach

22586Arthrodesis, pre-sacral interbody

technique, includes discectomy,

image guidance, bone graft &

posterior instrumentation, L5-S1.

(Cat III 0309T – L4-5 Add-on)

DO NOT USE WITH

22840-22848 Posterior Inst codes

20930-38 Bone graft codes

No Posterior Inst use Cat III codes

0195T L5-S1 No Inst

0196T L4-5 Add-On

Posterior Arthrodesis

(Skull, C1, C2)

22590

Occiput - C2 posterior

fusion

22595

C1-C2 posterior fusion

11

Arthrodesis –

Posterior/Posterolateral

22600 CervicalArthrodesis, posterior/posterolateral, cervical

below C2

22610 Thoracic

22612 Lumbar

22614 each additional interspace

Arthrodesis (Posterior) Interbody

22630

Arthrodesis, posterior lumbar interbody technique including

laminectomy and/or discectomy to prepare interspace (other

than for decompression) single interspace, lumbar

22632 each additional level

No prep/ fusion material in posterolateral gutters

MIS technique

Combined Posterior

Interbody/Posterolateral Arthrodesis

-22633

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

22634 each additional level

12

Summary of Posterior Lumbar Fusion

Algorithm for Posterior fusion

Negative Positive

Positive Positive Negative

22630 22633 22612

Posterior Approach

Posterolateral fusion

IB fusion IB fusion

Example

16 yo male with Grade IV-V spondy

PSF + IB L5-S1 22633

PL fusion L4-5 22614

Laminectomy L5 63012-59

IB L5-S1 22851

Inst L4-S1 22842

Local BG 20936

Cancellous allo 20930

In other words:

22614 is the additional level add-on

code for posterior or

posterolateral technique for

fusion/arthrodesis


code for PLIF


code for combined PLIF and

posterior or posterolateral

technique for fusion/arthrodesis

►(For facet joint fusion, see 0219T-0222T) ◄

13

Arthrodesis – Spinal Deformity

Posterior

22800 6 segments

22802 7-12 segments

22804 13 or more segments

Use with Spinal deformity codes

Arthrodesis – Spinal Deformity

Anterior

22808 2-3 segments

22810 4-7 segments


Kyphectomy

22818

Circumferential exposure of

spine AND resection of vertebral

segment(s) up to 2

22819 3 or more

Pediatric code

Myelomenigocele patients

14

Exploration

22830 Exploration of spinal fusion

(When exploration is reported with other

definitive procedures, including arthrodesis and

decompression, append modifier 51 to 22830)

Instrumentation Codes

22840 - 22849

Spinal Instrumentation – Posterior

22840

Posterior Non Segmental instrumentation

2 segments of fixation

22841

Spinous process fixation, e.g. wiring

22842 3-6 segments

22843 7-12 segments


15

Spinal Instrumentation – Anterior

22845 2-3 segments

22846 4-7 segments


Spinal Instrumentation – Special

22848

Pelvic fixation

22851

Application of intervertebral

biomechanical device(s) (eg.

synthetic cage or

methylmethacrylate) to vertebral

defect or interspace - coded per

interspace

Threaded Bone Dowels removed by editorial change

Spinal Instrumentation – Insertion and

Removal

22849

Reinsertion of spinal fixation

device (screws/ plates not IB)

22850

Removal Posterior non-

segmental instrumentation

22852

Removal Segmental Posterior

instrumentation

22855

Removal Anterior

instrumentation

16

New CPT language is added:

Codes 22849, 22850, 22852, and

22855 are subject to modifier 51

if reported with other definitive

procedure(s), including

arthrodesis, decompression, and

exploration of fusion.

Code 22849 should not be reported in

conjunction with 22850, 22852,

and 22855 at the same spinal

levels.

Example from prior

Ant Cervical fusion C6-7 22554

IB reinsertion C6-7 22851

Ant plate removal C4-C7 & new

plate placement C6-7 22849

Tips on Removal/ Reinsertion at same level

Only the appropriate insertion code (22840 -22848) 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 (22840-22848).

Disc Arthroplasty Codes

22856 - 22865

17

Cervical Disc Arthroplasty

22856 – Cervical TDA single level

Includes discectomy, nerve/cord

decompression

Excludes 22554, 22845, 22851, 63075

22858 second level TDA, Cervical

(New 2015)

22861 - Revision Cervical TDA

22864 - Removal Cervical TDA

Additional level: use T codes

0098T for revision

0095T for removal

Lumbar Disc Arthroplasty

22857 Lumbar TDA

Excludes 22558, 22845, 22851, 49010 (retroperitoneal approach)

22862 Revision Lumbar TDA

22865 Removal Lumbar TDA

Additional level: use T codes

0163T for arthroplasty

0165T for revision

0164T for removal

Bone Graft Codes

Non 22000

20930 - 20938

18

Bone Graft20930

Allograft for spine morselized

20931Allograft for spine structural

20936Local autograft, e.g. lamina, ribs

20937Autograft morselized separate incision

20938Autograft structural separate incision

Unlisted

22899

Expect Review/ Delay in Payment

Get Preauthorization

Possible uses

Stand alone Dynamic instrumentation

Annular Repair

Miscellaneous

19

Percutaneous SI fusion

27279Arthrodesis, SI joint, percutaneous or

minimally invasive (indirect

visualization), with image guidance,

includes obtaining bone graft when

performed and placement of

transfixing device

For bilateral procedures add modifier 50

For open SI fusion use 27280

Miscellaneous – Skull

20660 - Application Cranial Tongs

20661 - Application Halo

20664 - Application Halo 6 or More pins placed

20665 - Removal Halo/Tongs placed by another MD

Thank You

North American Spine Society CODING UPDATE 2017

Conquering Your Coding Hurdles

Las Vegas

CPT: 63000 Series

Codes and Integrated Anatomy

Gregory J. Przybylski, MD

Principles of Spine Coding

• Four principal components

– Decompression (Primary)

• 63000 Series (Neurosurgical Section)

• Add-On: Each additional level codes

– No -51 modifier appended

– Valued for intra-operative work only

– Arthrodesis (Primary)

• 22000 Series (Musculoskeletal)

– Instrumentation (Add-on)

• 228XX Series

– Bone Graft Harvest (Add-on)

• 2093X Series

Choosing the Final Code

• Location (Spinal Segment)

– Cervical, thoracic, lumbar,

sacral

– Junctions

• Surgical Approach

– Anterior

– Anterolateral/Lateral

extracavitary

– Transthoracic

– Thoracolumbar/Posterior

– Trans/Retroperitoneal

• Entry into Dura/Cord

• Stays outside dura

(extradural)

• Cuts into dura (intradural)

• Cuts into spinal cord

(intramedullary)

• Pathology

– Consider purpose of surgery

– Disc

– Neoplasm

– Non-neoplasm

– Vascular

Decompression Definitions

• Bone Segment

– Single vertebra

• Ex: L5 laminectomy

• Anterior (Vertebral body)

• Posterior (Pedicle, facet, lamina, sp, pars)

• Neurologic Decompression

– Joint between adjacent segments

• Ex: L4-L5 disc/foraminotomy

• Nerve roots, foramen

– Interspace• Anterior (Disc space)

• Posterior (Facet joint)

CPT Organization

• Percutaneous procedures

– 62263-62319

• Posterior laminectomy for

disc/stenosis

– 63001-63066

• Anterior disc/corpectomy

– 63075-63091


neoplasm

– 63250-63290

• Anterior corpectomy for

neoplasm

– 63300-63308


CSF

– 63170-63200

• Neurostimulators

– 63650-63688

Percutaneous Spine

• Lumbar puncture, drainage

– 0 Day Global

– Lum Punct: 62270

• wRVU 1.37, tRVU 2.25

– Lum Drain: 62272

• wRVU 1.35, tRVU 2.43

– Blood Patch: 62273

• wRVU 2.15, tRVU 3.26

– 77003 may be used

• Fluoroscopic guidance and

localization of needle or

catheter tip

• Includes injection of contrast

• Percutaneous disc

decompression (Any

method, laser)

– 90 Day Global

– 62287

• wRVU 9.03, tRVU 16.50

– Reported once per session,

even if multiple levels

– Fluoroscopic guidance use

77002

– NOTE: 62380 Endoscopic

discectomy NEW for 2017

Percutaneous Disc Decompression• Percutaneous intradiscal

electrothermal annuloplasty

– 10 Day Global

– 22526

• wRVU 5.85, tRVU 9.72/65.60

– 22527 Add’l Level

• wRVU 3.03, tRVU 4.60/55.39

• Reported once (not per level)

– Unilateral or bilateral

• Do not append modifier 50

– Includes fluoroscopy

• Do not report 77002/77003

– 01936

• Anesthesia for percutaneous proc’s

Percutaneous Disc Decompression

• Percutaneous Annuloplasty

(non-IDET)

– 0062T

• Percutaneous Intradiscal

Annuloplasty, any method except

electrothermal, unilateral or

bilateral including fluoroscopic

guidance; single level

– 0063T

• One or more additional levels

Endoscopic Disc Decompression

• Laminotomy, facetectomy, foraminotomy (Endoscopic)– 90 Day Global

– “And/Or Excision of Herniated Disc”• Use 62287 if percutaneous

– 62380 L only• Carrier-priced

– Endoscopic: continuous direct visualization via endoscope

– Open: direct visualization through surgical opening

– Percutaneous: indirect visualization

– Unilateral code, -50 for bilateral

– Do not report with 63030, 63056

Disc Decompression

• Laminotomy, facetectomy, foraminotomy (Open)– 90 Day Global

– “And/Or Excision of Herniated Disc”• Use 63045-63048 if without disc excision

– 63020 C• wRVU 16.20, tRVU 33.81

– 63030 L• wRVU 13.18, tRVU 28.20

– 63035 C/L add’l level (No -51)• wRVU 3.15, tRVU 5.61

– Includes use of endoscope• Do not refer to as “Percutaneous,

Endoscopic”

– Unilateral codes, -50 for bilateral

Laminotomy - Disc• Laminotomy (hemilam) with decompression and/or

excision, re-exploration, single interspace

– More than 90 days later

– Unilateral codes, -50 modifier if bilateral

– 63040 C

• wRVU 20.31, tRVU 40.58

– 63043 C Add-on level

• No -51, Carrier-priced

– 63042 L

• wRVU 18.76, tRVU 37.67

– 63044 L Add-on level

• No -51, Carrier-priced

– Re-do laminectomy (uni or bilateral) without disc excision

should use 63045-63048.

Laminectomy

• Laminectomy only, 1-2 segments

– Central stenosis, decompression

• Does not include facetectomy, foraminotomy or diskectomy.

• Partial laminectomy use 63020-63035, 63045-63048.

– 63001 C

• wRVU 17.61, tRVU 36.23

– 63003 T

• wRVU 17.74, tRVU 36.18

– 63005 L (Except for spondylolisthesis)

• wRVU 16.43, tRVU 34.45

– 63011 S

• wRVU 15.91, tRVU 31.72

Laminectomy

• Laminectomy only, > 2 segments

– Central stenosis, decompression

• Does not include facetectomy, foraminotomy or diskectomy.

• Partial laminectomy use 63020-63035, 63045-63048.

– 63015 C

• wRVU 20.85, tRVU 43.30

– 63016 T

• wRVU 22.03, tRVU 44.52

– 63017 L

• wRVU 17.33, tRVU 36.67

• Use 63012 if laminectomy for spondylolisthesis (Gill)

Laminectomy for Spondylolisthesis

• 63012 (Gill Procedure)

– Laminectomy with removal of abnormal

facets and/or pars interarticularis with

decompression of cauda equina and nerve

roots for spondylolisthesis, lumbar

• wRVU 16.85, tRVU 34.69

– May not report bilateral (No -50 modifier)

– Used for diagnosis of spondylolisthesis,

spondylolysis, spondylosis

• Not for disc disease or stenosis only

Laminectomy

• Laminectomy, facetectomy and foraminotomy, w/decomp

– Diagnosis: Spinal or lateral recess stenosis

• Use 63001-63011, 63015-63017 if no facetectomy, foraminotomy or diskectomy

performed

– Unilateral or bilateral

– 63045 Cervical

• wRVU 17.95, tRVU 37.58

– 63046 T

• wRVU 17.25, tRVU 35.58

– 63047 L

• wRVU 15.37, tRVU 32.06

– 63048 C/T/L each additional (No-51)

• wRVU 3.47, tRVU 6.19

– 2008 change allowed add-on instrumentation codes

(22840-22855) without a fusion

Laminoplasty

• Cervical spine

– 2 or more segments

– Foraminotomies not included

– Alternative technique to 63001/63015

• 63050 Laminoplasty with decompression

– wRVU 22.01, tRVU 43.79

• 63051 With reconstruction of posterior bony elements including miniplates and placing bone

– wRVU 25.51, tRVU 49.79

– Bone graft may be reported separately.

• Do not code with another decompression or instrumentation code at same level/segment.

– For stenosis, if osteoplastic reconstruction after another primary intraspinal procedure then use 63295

Posterior/Post. Lat. Approach

• Transpedicular approach with

decompression

– Including transfacet, lat extraforam approach

– Far lateral intervertebral disc, corpectomy

• For excision of intraspinal lesions use 63250-63290.

– Bilateral code, disk or body

• Unilateral typically does not remove much lamina

– 63055 T

• wRVU 23.55, tRVU 47.59

– 63056 L

• wRVU 21.86, tRVU 43.21

– 63057 Each additional level

• No -51, use for each add’l segment T or L

• wRVU 5.25, tRVU 9.37

Posterior/Post. Lat. Approach

• Costovertebral approach with

decompression

– Costovertebral, costotransversectomy,

costotransfacet

– Herniated disk, corpectomy

• For excision of intraspinal lesions use

63250-63290.

– 63064 T

• wRVU 26.22, tRVU 51.75

– 63066 Each additional level

• No -51 as it is an add-on code

• wRVU 3.26, tRVU 6.08

Lateral Extracavitary

• Lateral extracavitary approach– Vertebral corpectomy, partial or complete,

LEC approach with decompression

– Unilateral code

– Disk or body for decompression• Typically for tumors, fractures

– Not XLIF or AxiaLIF!

• 63101 T– wRVU 34.10, tRVU 67.55

• 63102 L– wRVU 34.10, tRVU 66.20

• 63103 Each additional level– No -51

– wRVU 4.82, tRVU 8.57

• Note similar arthrodesis codes, microscope

Anterior Approach

• Diskectomy, anterior, with decompression, including osteophytectomy– Microdissection (69990) included.

– Arthrodesis use 22554-22585.

– Bone graft use 20930-20938.

• 63075 C– wRVU 19.60, tRVU 39.44

• 63076 C Each add’l level (No -51)– wRVU 4.04, tRVU 7.26

• 63077 T– wRVU 22.88, tRVU 43.40

• 63078 T each additional (No -51)

– wRVU 3.28, tRVU 5.67

Corpectomy via Approach

• Vertebral corpectomy, part or comp, ant appr, w/ decomp– Notes

• Includes diskectomy above a/o below segment.

• Corp for exc of intrasp lesion use 63300-63308.

• Transoral approach use 61575, 61576.

– 63081 C (Ant-AntLat)• wRVU 26.10, tRVU 51.19

– 63085 T (Ant-AntLat) (Transthoracic)• wRVU 29.47, tRVU 55.80

– 63087 TL (Thoracolumbar)• wRVU 37.53, tRVU 70.26

– 63090 L (Trans/retroperitoneal)• wRVU 30.93, tRVU 56.83

– Additional Levels (No -51)• 63082 C, 63086 T, 63088 TL, 63091 L

Corpectomy- How Much?

• Cervical Corpectomy

– 1/2 or more

• Thoracic & Lumbar

Cortectomy

– 1/3 or more

• Includes discectomies above

and below

Laminectomy (Vascular)

• Irrespective of number of lamina excised– No additional segment or interspace

codes

• Vascular malformation– 63250 C

• wRVU 43.86, tRVU 87.67

– 63251 T• wRVU 44.64, tRVU 88.74

– 63252 L• wRVU 44.63, tRVU 89.06

Laminectomy (Non Neoplasm)

• No add’l seg or intersp codes

• Extradural, non-neoplasm– Include cysts, hematomas, and

other masses.

– Synovial cysts may be reported with this or laminectomy code.

– 63265 C• wRVU 23.82, tRVU 48.79

– 63266 T• wRVU 24.68, tRVU 50.28

– 63267 L• wRVU 19.45, tRVU 39.92

– 63268 S• wRVU 20.02, tRVU 40.77

• Intradural, non-neoplasm– 63270 C

• wRVU 29.80, tRVU 60.97

– 63271 T• wRVU 29.92, tRVU 60.42

– 63272 L • wRVU 27.50, tRVU 55.20

– 63273 S • wRVU 26.47, tRVU 53.65

Laminectomy (Neoplasm)

• Irrespective of number of lamina excised

• Extradural, neoplasm– 63275 C

• wRVU 25.86, tRVU 52.60

– 63276 T• wRVU 25.69, tRVU 52.31

– 63277 L• wRVU 22.39, tRVU 45.25

– 63278 S• wRVU 22.12, tRVU 46.28

• Intradural, extramedullaryneoplasm

– 63280 C• wRVU 30.29, tRVU 61.81

– 63281 T• wRVU 29.99, tRVU 61.34

– 63282 L• wRVU 28.15, tRVU 57.68

– 63283 S• wRVU 26.76, tRVU 55.34

• Intradural, intramedullary neoplasm

– 63285 C• wRVU 38.05, tRVU 77.21

– 63286 T• wRVU 37.62, tRVU 75.22

– 63287 TL• wRVU 40.08, tRVU 81.02

• Combined intra/extradural– 63290 CTLS

• wRVU 40.82, tRVU 81.98

Laminoplasty

• Add-on code

– List separately in addition to code for

primary procedure

– Developed for tumor reconstruction

• Osteoplastic reconstruction of dorsal

spinal elements following primary

intraspinal procedure

– Do not code with fusion, instr, decomp

at the same vertebral segment.

• 63295

– wRVU 5.25, tRVU 9.82

– NOT 63050 or 63051!

Corpectomy (Neoplasm)

• Code each vertebral segment excised– Use 63290 if combined with

lam for bx/exc of intraspinallesion of any level.

• Intraspinal but extradural– 63300 C (Ant-AntLat)

• wRVU 26.80, tRVU 53.59

– 63301 T (Transthoracic)

• wRVU 31.57, tRVU 60.67

– 63302 TL (Posterior)

• wRVU 31.15, tRVU 63.13

– 63303 L/S (Retrotransperito)

• wRVU 33.55, tRVU 66.02

• Intraspinal and intradural– 63304 C (Ant-AntLat)

• wRVU 33.85, tRVU 67.99

– 63305 T (Transthoracic)• wRVU 36.24, tRVU 70.45

– 63306 TL (Posterior)• wRVU 35.55, tRVU 60.43

– 63307 L/S (Retrotransperito)• wRVU 34.96, tRVU 63.37

• Each additional level, intraspinal (Either ED/ID)– No -51

– 63308 CTLS• wRVU 5.24, tRVU 9.47

Laminectomy (CSF)

• Irrespective of number of segments

• Shunt syrinx (includes laminectomy)– 63172 subarach

• wRVU 19.76, tRVU 41.31

– 63173 pleural/peritoneal

• wRVU 24.31, tRVU 50.06

• Shunt CSF, lumboperitonealshunt– 63740 with lami

• wRVU 12.63, tRVU 27.28

– 63741 without lami

• wRVU 9.12, tRVU 19.69

– 63744 revise, replace

• wRVU 8.94, tRVU 19.27

– 63746 remove w/o replace

• wRVU 7.33, tRVU 17.60

• Repair dura/CSF leak

– 63707 without lami

• wRVU 12.65, tRVU 26.77

– 63709 with lami

• wRVU 15.65, tRVU 33.02

– 63710 spinal dural graft

• wRVU 15.40, tRVU 31.47

Other Spine

• Computer-assisted Navigation 61783

– No -51 modifier

– Brain surgery using computer

– wRVU 3.75, tRVU 6.83

– Local coverage policies (Noridian, WPS)

• Microdissection 69990 (Microsurgery add-on)

– Included in 63075-77

– No -51 modifier

– wRVU 3.46, tRVU 6.43

• Unlisted 64999 (Nervous System Surgery)

– Carrier-priced

THANK YOU

1

North American Spine SocietyCoding UpdateLas Vegas, NV

Donna M. Lahey, RNFACEO, Spine Institute of Arizona

OFFICE OF THE INSPECTOR GENERAL

1700 professionals-Conduct investigations, audits and evaluations aimed at identifying and fighting fraud, waste and abuse.

Each year they develop a Work Plan in October which includes new and ongoing enforcement projects and high risk areas of activity they will be investigating in the upcoming fiscal year and reason why.

OIG also reports to Congress twice a year via a second publication called the Semi-annual report which summarizes the OIG’s most significant findings and recommendations as well as investigative outcomes and outreach activities.

A third publication, the Compendium of Unimplemented Recommendations, describes open recommendations from prior periods.

All three serve to inform Congress on the OIG’s completed work and findings, their enforcement actions and recommendations, and how the HHS can save money and improve the Medicare and Medicaid programs.

FY 2016 Accomplishments (OIG’S Semiannual Report form April1,2016-September 30, 2016

For First half of FY 2016, the OIG reported expected recoveries of over $5.66 billion

$1.2 billion in audit receivables $4.46 billion in investigative receivables

$953 million in non-HHS investigative receivables resulting from our work in areas such as the States’ shares of Medicaid restitution.

3,635 individuals and entities excluded from participation in Federal health care programs

844 criminal actions against individuals or entities that engaged in crimes against HHS programs

708 civil actions, which include false claims and unjust-enrichment lawsuits filed in Federal district court, CMP settlements, and administrative recoveries related to provider self-disclosure matters.

2

In June 2016 the Health Care Fraud Strike Force led an unprecedented nationwide sweep in 36 Federal districts, with the assistance of 24 State Medicaid Fraud Control Units (MFCU).

The sweep resulted in criminal and civil charges against 301 individuals, including 61 doctors, nurses, and other licensed medical professionals, for their alleged participation in health care fraud schemes involving approximately $900 million in false billings.

For more information on this takedown, visit the Strike Force website at https://oig.hhs.gov/fraud/strike-force/highlights.html?width=600&height=540

PAST TOPICS

Physicians: Incident-To Services-To determine whether payment for services had a higher error rate than that for non-incident-to services. A 2009 OIG review found that when Medicare allowed physicians’ billings for more than 24 hours of services in a day, half of the services were not performed by a physician. They also found that unqualified nonphysicians performed 21 percent of the services that physicians did not perform personally.

Physician-Owned Distributors of Spinal Implants- Review and determine the extent to which physician-owned distributors (POD) provide spinal implants purchased by hospitals. Determine whether PODs were associated with high use of spinal implants. Congress has expressed concern that PODs could create conflicts of interest and safety concerns for patients

Evaluation and Management Services-Use of Modifiers During the Global Surgery Period. The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period

RECENT TOPICS

Evaluation and management services— Review of multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities. Context—Medicare contractors noted an increased frequency of medical records with identical documentation across services.

Electrodiagnostic testing—Questionable billing and payments. Review of Medicare claims data to identify questionable billing for electrodiagnostic testing and determine the extent to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services. Context— The use of electrodiagnostic testing for inappropriate financial gain could pose a growing vulnerability to Medicare.

3

Chiropractic services—Part B Payments for Noncovered Services. Medicare’s covered chiropractic services include only treatment by means of manual manipulation of the spine to correct subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment. Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable.

Chiropractic services—Questionable billing- Previous OIG work demonstrated a history of vulnerabilities relative to inappropriate payments for chiropractic services, including recent work that identified a chiropractor with a 93-percent claim error rate and inappropriate Medicare payments of about $700,000. Although chiropractors may submit claims for any number of services, Medicare reimburses claims only for manual manipulations or treatment of subluxations of the spine that provides "a reasonable expectation of recovery or improvement of function.“

Medicare Part D spending for commonly abused opioids exceeded $4 billion in 2015, and

spending for compounded topical drugs increased more than 3,400 percent since 2006.

This data brief builds on OIG’s June 2015 data brief, which described trends in Part D spending and identified questionable billing by pharmacies.

It updates information on spending for commonly abused opioids and provides data on the dramatic growth in spending for compounded drugs.

OIG will conduct investigations and reviews to address the ongoing problems created by opioid

abuse and the emerging problems linked to compounded drugs.

CMS has already taken steps to combat the problems associated with commonly abused opioids, such as identifying outlier prescribers. However, the data brief concluded that CMS needs to take additional action.

CMS also needs to assess the implications of the compounded drug trends identified in this data brief and take action where needed to protect the integrity of the program.

Payments to providers and nonphysician practitioners who order and refer Medicare services and supplies -CMS requires that physicians and nonphysician practitioners who order certain services, supplies, and/or durable medical equipment (DME) be Medicare-enrolled physicians or nonphysician practitioners. Under this Work Plan target, the OIG will review select Medicare services, supplies, and DME to determine whether the payments made to the providers were in accordance with Medicare requirements. In other words, were the providers who billed these charges legally allowed to do so? If providers in your practice order such supplies and equipment, but are not enrolled in the Medicare program, that's a problem. If your practice has ineligible providers who have ordered and have been paid for these services and supplies, it may be at risk for an audit or payback.

4

OIG on the Web: http://www.oig.hhs.gov

OIG on Twitter: http://twitter.com/OIGatHHS

The place of service can greatly affect reimbursement

Medicare reimburses physicians based on Relative Value Units (RVUs). An RVU has three components: work, practice expense, and malpractice. The place of service is part of the practice expense component, and procedures that can be performed in either a facility or nonfacility setting have different practice expense RVUs, depending on the place of service.

CMS' Inpatient Prospective Payment System

Hospitals agree to pre-determined rates in order to serve Medicare patients.

About 3,400 acute-care hospitals and 435 long-term care hospitals receive payments under the IPPS.

Hospitals generally receive IPPS payment on a per-discharge or per-case basis for Medicare beneficiary inpatient stays.

Discharges are assigned to diagnosis-related groups, which sorts them by similar clinical conditions and procedures administered by the hospital during the stay.

5

CMS identifies services that should be performed in the inpatient setting. These services are itemized on the inpatient list, also known as the inpatient-only list.

Services will only be reimbursed to hospitals if they are provided in the inpatient setting. Services are included based on:

The nature of the procedure

The underlying physical condition of the patient

The need for at least 24 hours of postoperative recovery time or monitoring before safe discharge

Medicare will not pay the facility for inpatient list services if they are provided outside of the inpatient setting.

The inpatient list does not affect physician reimbursement. If the medical record documents the medical necessity of a service, then the physician will typically receive the Medicare Part B reimbursement for an inpatient list service, regardless of the setting.

CMS maintains and updates the list annually as part of the OPPS rulemaking process.

As long as the medical record shows that the service was medically necessary, the physician and the hospital will generally be reimbursed.

Other factors could prevent a hospital from receiving full reimbursement for services provided in the inpatient setting that are not on the inpatient list.

A RAC audit might determine that an inpatient admission was not medically necessary. Surgeons should clearly document both the medical necessity of the procedure as well as the medical necessity of the inpatient admission.

6

The list is included as Addendum E to the hospital OPPS rule and is posted on the CMS website under the “Hospital Outpatient Regulations and Notices” tab. (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html

On the same CMS website, under the “Addendum A and Addendum B Updates” tab, Addendum B lists the payment status indicator (SI) for all CPT codes. The payment SIs are updated quarterly and indicate whether a service is payable under the Inpatient PPS, the Hospital Outpatient PPS, or another payment system.

If a code has the SI of “C,” that code is on the inpatient list and the facility will receive payment only if performed in the inpatient setting.

If a code has the SI of “T, J1, N” the code is payable under the Hospital Outpatient PPS, but may also be paid under the Inpatient PPS.

Addendum B.-Final OPPS Payment by HCPCS

Code for CY 2016

Data Addendum B.-Data Status Indicators,

Data APC Assignments, and Data Comment

Indicators Used in the Development of the

Geometric Mean Costs for HCPCS codes and

APCs for CY 2016CPT codes and descriptions only are copyright 2015

American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Dental codes

(D codes) are copyright 2015 American Dental Association. All Rights Reserved. Short Descriptor 2016 NPRM data SI

22551 Neck spine fuse&remov bel c2 J1

22552 Addl neck spine fusion N

22554 Neck spine fusion J1

22556 Thorax spine fusion C

22558 Lumbar spine fusion C

22585 Additional spinal fusion C

22586 Prescrl fuse w/ instr l5-s1 C

22590 Spine & skull spinal fusion C

22595 Neck spinal fusion C

22600 Neck spine fusion C


22612 Lumbar spine fusion J1

22614 Spine fusion extra segment N


22632 Spine fusion extra segment C

22633 Lumbar spine fusion combined C


• If a code has the SI of “C,” that code is on the inpatient list and the facility will receive payment only if performed in the inpatient setting.

• If a code has the SI of “T, J1, N” the code is payable under the Hospital Outpatient PPS, but may also be paid under the Inpatient PPS.

Addendum B.-Final OPPS Payment by HCPCS Code

for CY 2016

Data Addendum B.-Data Status Indicators, Data APC Assignments,

and Data Comment Indicators Used in the Development of the

Geometric Mean Costs for HCPCS codes and APCs for CY 2016

CPT codes and descriptions only are copyright 2015 American

Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Dental codes (D codes) are copyright 2015

American Dental Association. All Rights Reserved. Short Descriptor 2016 NPRM data SI

22800 Post fusion </6 vert seg C

22802 Post fusion 7-12 vert seg C

22804 Post fusion 13/> vert seg C

22808 Ant fusion 2-3 vert seg C


22812 Ant fusion 8/> vert seg C

22818 Kyphectomy 1-2 segments C

22819 Kyphectomy 3 or more C

22830 Exploration of spinal fusion C

22840 Insert spine fixation device C








22848 Insert pelv fixation device C

22849 Reinsert spinal fixation C

22850 Remove spine fixation device C


22853 Ins biomechanical device N



22856 Cerv artific diskectomy J1

22857 Lumbar artif diskectomy C

22858 Second level cer diskectomy C

22859 Insj biomechanical device N

22861 Revise cerv artific disc C

22862 Revise lumbar artif disc C

22864 Remove cerv artif disc C

22865 Remove lumb artif disc C

• If a code has the SI of “C,” that code is on the inpatient list and the facility will receive payment only if performed in the inpatient setting.• If a code has the SI of “T, J1, N” the code is payable under the Hospital Outpatient PPS, but may also be paid under the Inpatient PPS

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html

7

Addendum B.-Final OPPS Payment by HCPCS

Code for CY 2016

Data Addendum B.-Data Status Indicators,

Data APC Assignments, and Data Comment

Indicators Used in the Development of the

Geometric Mean Costs for HCPCS codes and

APCs for CY 2016CPT codes and descriptions only are copyright 2015

American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Dental codes (D

codes) are copyright 2015 American Dental Association. All Rights Reserved. Short Descriptor 2016 NPRM data SI

63001 Remove spine lamina 1/2 crvl J1

63003 Remove spine lamina 1/2 thrc J1

63005 Remove spine lamina 1/2 lmbr J1

63011 Remove spine lamina 1/2 scrl J1

63012 Remove lamina/facets lumbar J1

63015 Remove spine lamina >2 crvcl J1

63016 Remove spine lamina >2 thrc J1

63017 Remove spine lamina >2 lmbr J1

63020 Neck spine disk surgery J1

63030 Low back disk surgery J1

63035 Spinal disk surgery add-on N

63040 Laminotomy single cervical J1

63042 Laminotomy single lumbar J1

63043 Laminotomy addl cervical N

63044 Laminotomy addl lumbar N

63045 Remove spine lamina 1 crvl J1

63046 Remove spine lamina 1 thrc J1

63047 Remove spine lamina 1 lmbr J1

63048 Remove spinal lamina add-on N

63050 Cervical laminoplsty 2/> seg C

63051 C-laminoplasty w/graft/plate C

63055 Decompress spinal cord thrc J1

63056 Decompress spinal cord lmbr J1

• If a code has the SI of “C,” that code is on the inpatient list and the facility will receive payment only if performed in the inpatient setting.

• If a code has the SI of “T, J1, N” the code is payable under the Hospital Outpatient PPS, but may also be paid under the Inpatient PPS

T - Procedure or Service, Multiple Procedure Reduction Applies Paid under OPPS; separate APC payment.

N - Items and Services Packaged into APC Rates Paid under OPPS; payment is packaged into payment for other services. Therefore, there is no separate APC payment.

J1 -Hospital Part B services paid through a comprehensive APC Paid under OPPS; all covered Part B services on the claim are packaged with the primary "J1" service for the claim, except services with OPPS SI=F,G, H, L and U; ambulance services; diagnostic and screening mammography; all preventive services; and certain Part B inpatient services.

C -Inpatient Procedures Not paid under OPPS. Admit patient. Bill as inpatient

More than 4,000 hospitals receive reimbursement through Medicare's Outpatient Prospective Payment system.

Provides payment for most hospital outpatient department services and partial hospitalization services administered by hospital outpatient departments and community mental health centers.

OPPS rates vary depending on ambulatory payment classification groups for procedures and services.

8

CMS uses the following criteria:

Most outpatient departments are equipped to provide the services to the Medicare population

The simplest procedure described by the CPT code be performed in most outpatient departments

The procedure is related to codes that CMS has already removed from the inpatient list

The procedure is being performed in numerous hospitals on an outpatient basis

The procedure can be performed appropriately and safely in an ASC and is on the list of approved ASC procedures, or CMS has proposed that it be added to the ASC list

There are more than 5,300 Medicare-certified ASCs paid under the OPPS. OPPS payment amounts vary based on the APC groups to which services or procedures are assigned.

Earlier this summer, in the same rule that included proposed payment and policy changes for hospital outpatient departments, CMS released proposed payment and policy updates for ASCs for 2015.

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2017(Including Surgical Procedures for Which Payment is Packaged)

CPT codes and descriptions only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Dental codes (D codes) are copyright 2015/16 American Dental

Association. All Rights Reserved.

HCPCS Code Short Descriptor

Proposed to be Subject

to Multiple Procedure

Discounting

22513 Perq vertebral augmentation Y

22514 Perq vertebral augmentation Y

22515 Perq vertebral augmentation N

22551 Neck spine fuse&remov bel c2 Y


22554 Neck spine fusion Y

22585 Additional spinal fusion N

22612 Lumbar spine fusion Y


22840 Insert spine fixation device N






9

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 20167(Including Surgical Procedures for Which Payment is Packaged)

CPT codes and descriptions only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Dental codes (D codes) are copyright 2015/16 American

Dental Association. All Rights Reserved.

HCPCS Code Short Descriptor

Proposed to be

Subject to Multiple

Procedure

Discounting

63001

Removal of spinal

lamina Y

63003

Removal of spinal

lamina Y

63005

Removal of spinal

lamina Y

63020

Neck spine disk

surgery Y

63030

Low back disk

surgery Y

63042

Laminotomy single

lumbar Y

63044

Laminotomy addt’l

level N1

63045

Removal of spinal

lamina Y

63046

Remove spine

lamina 1 thrc Y

63047

Remove spine

lamina 1 lmbr Y

63055

Decompress spinal

cord thrc Y

63056

Decompress spinal

cord lmbr Y

Removal of Spine Codes from the Inpatient-Only List.

CMS has removed the following spine codes from the inpatient-only list:

◦ CPT 22840 (Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxialtransarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure));

◦ CPT 22842 (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));

◦ CPT 22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure));

◦ CPT 22858 (Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure))

CMS has added the following spine codes to the list of ASC Covered Surgical Procedures:

20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from the same incision (List separately in addition to code for primary procedure)

20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

20938 Autograft for spine surgery only (includes harvesting the graft); structural, biocortical or tricortical (through separate skin fascial incision)

22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomyand decompression of spinal cord and/or nerve roots; cervical C2, each additional interspace (List separately in addition to code for separate procedure)

22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation)

22842 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation)

22845 Anterior instrumentation; 2 to 3 vertebral segments N1 22851 Application of intervertebralbiomechanical device(s) (eg, synthetic cage(s), methlmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)

10

The Medicare program currently pays significantly different rates for the same services provided in different settings.

According to the Medicare Payment Advisory Commission, Medicare paid hospital outpatient departments 78 percent more on average than ambulatory surgery centers for the same procedure in 2013.

Denials today are becoming increasingly more common.

One of the top reasons for denials is documentation or…. lack thereof

WHY???Medical terminology doesn’t match the insurance

company's medical guidelines terminology for approval

Documentation does not support the performance of the service.

Documentation does not support medical necessity

Medical terminology does not match the insurance company's medical guidelines terminology for approval

USE CPT LANGUAGE

INCORRECT- “ L4-5 Spinal Stenosis Decompression”

There are several different CPT codes for decompression that could be used to code this procedure

CORRECT-“L4-5 Partial Laminectomy, Facetectomy, Foraminotomy for Stenosis Decompression”

11

PREOPERATIVE DIAGNOSES: L5 spinal stenosis, right lateral recess, secondary to

ligamentum flavum infolding and hypertrophy, facet capsular and boney hypertrophy, neuroforaminal narrowing secondary to disc space height collapse and bulging

Right leg radiculopathy/ radiculitis. Lesser Mechanical back pain. Epidural Fibrosis previous Laminectomy L5

PROCEDURES: L5 right unilateral spinal stenosis decompression:

partial laminectomy, partial facetectomy, partial foraminotomy with decompression of cauda equina and nerve roots.

Microscopic lysis of neural and vascular adhesions.

Medical terminology doesn’t match the insurance company's medical guidelines terminology for approval

Documentation does not support the performance of the service

Documentation does not support the performance of the service

When dictating, if a procedure appears in the procedure section of the operative report, make sure it also appears in the body of the report.

12

PREOPERATIVE DIAGNOSES: L5 spinal stenosis, right lateral recess, secondary to

ligamentum flavum infolding and hypertrophy, facet capsular and boney hypertrophy, neuroforaminal narrowing secondary to disc space height collapse and bulging


PROCEDURES: L5 right unilateral spinal stenosis decompression:

partial laminectomy, partial facetectomy, partial foraminotomy with decompression of cauda equina and nerve roots.

Microscopic lysis of neural and vascular adhesions.

FINDINGS: Specific Findings/ Items of note include: Degenerative and mild

congenital L5 nerve root compression and right lateral recess spinal stenosis was seen secondary to ligamentum flavum hypertrophy, facet capsular and bony hypertrophy, disc bulging, and foraminal narrowing secondary to disc space height loss, in addition to a boney osteophyte.

Intra-canal decompression was performed using the microscope. Microscopic lysis of neural and vascular adhesions was performed using micro-instruments, including the Rhoton microscopic instruments (curettes and nerve hooks, etc.); the decompression was tedious because of the epidural fibrosis from the previous surgery. The micro- instruments were used to perform fine dissection of the neural and vascular structures and epidural fibrosis adhesions The microscope was necessary, as the neural and vascular structures dealt with, as well as the epidural fibrosis adhesions, were too small to be safely seen and operated without the microscope.

The L5 nerve root was seen to be compressed, and after the procedure were visualized as being decompressed.

Decompression Details Lumbar neural decompression of the stenosed L5 was then performed by

partial laminectomies, partial facetectomies, and partial foraminotomies, as well as the excision of all neurologically compressive soft tissues. Ligamentum flavum and portions of the anterior facet capsule were resected as necessary to effect neurologic spinal stenosis decompression. Throughout the laminectomy procedures, the pars interarticularis were identified and carefully preserved.

A right L5 laminectomy was performed. Using a combination of the high- speed diamond burr, Kerrison ronguers, and spinal micro-curettes and nerve hooks, partial inferior laminectomy was performed sufficient to expose the ligamentum flavum and safely resect it, revealing the cauda equina dura below. Decompressive partial medial facetectomy and foraminotomy were then performed, exposing laterally enough to reveal the exiting L5 nerve root, which was visualized as being compressed. This root was visualized and decompressed of bony and soft tissue stenotic elements, sufficient to relieve all spinal stenosis affecting the nerve root. At the end of this decompression portion of the procedure, the neural elements were free and clear of compression and completely mobilizable, and the foramina were free and clear of compression, impingement, or obstruction.

13

Medical terminology doesn’t match the insurance company's medical guidelines terminology for approval

Documentation does not support the performance of the service.

Documentation does not support medical necessity

Documentation does not support Medical Necessity

Review Coverage Policies and Document Criteria for Medical Necessity

To support medical necessity the physician must submit information such as:

History including the duration/character/location/radiation of pain

Any limitation of activities of daily living

Physical examination, and imaging reports specific to the surgical procedure

Conservative Therapy Course- History and Duration

PREOPERATIVE DIAGNOSES: L5 spinal stenosis, right lateral recess, secondary to ligamentum flavum infolding and

hypertrophy, facet capsular and boney hypertrophy, neuroforaminal narrowing secondary to disc space height collapse and bulging


PROCEDURES: L5 right unilateral spinal stenosis decompression: partial laminectomy, partial facetectomy,

partial foraminotomy with decompression of cauda equina and nerve roots. Microscopic lysis of neural and vascular adhesions.

INDICATIONS FOR THE PROCEDURE: For the full indications for this surgery, please see the office notes.

This patient has the diagnoses outlined above in the “Preoperative Diagnoses,” confirmed on X-ray and MRI and EMG, and has corresponding symptoms and examination findings consistent with an L5 Radiculopathy including muscle weakness and sensory deficit. She has residual back pain and L5 dermatomal radicular symptoms for over six months that have been refractory to multiple conservative approaches to pain, including activity restrictions, medications including anti inflammatories and muscle relaxers, and a rehabilitation- based physical therapy program including a home based exercise program, as well as epidural steroid injections which afforded no significant relief. Indeed, these symptoms are worsening and interfering greatly with daily activities. At this point in time, after failing a conservative approach to the problems outlined above, the patient has elected to proceed with the surgery as outlined above.

14

In an October 2013 Pre-Payment Review, Medicare MAC Palmetto GBA either completely or partially denied 168 out of 251 Spinal Fusion claims (65%), rejecting $4.15 million out of $6.36 million in claims due to insufficient MND.

Some of the latest MAC Recovery Audit findings have revealed high percentages of Medical Necessity Documentation( MND) errors in Pre- & Post-Payment reviews of Spinal Fusion procedure DRG-460.

Deficiencies in MND lead to respectively reported error rates of 73% and 64% in Post-Payment reviews by Medicare MAC’s

MAINTAIN DOCUMENTATION IN THE MEDICAL RECORDS THAT SUBSTANTIATES THE NEED FOR LUMBAR SPINAL FUSION SURGERY

Office notes/hospital record, including history and physical

Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management) when applicable. This therapy does not have to be under the direction of the operating surgeon.

Interpretation and reports for X-rays, MRI’s, CT

Documentation of smoking history, and that the patient has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation if accepted(if applicable)

Complete operative report outlining operative approach used and all the components of the spine surgery

Medical record documentation must be made available to Medicare upon request. If documentation does not meet the criteria for the service(s) rendered or if documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act Appendices

15

The most common reason for denial of spinal fusion services is lack of specific information regarding conservative treatment attempted and failed prior to surgery.

Documentation of prior conservative treatments attempted or completed and if not done:

Documentation of a condition that would make conservative treatment inappropriate.

“Failed conservative/outpatient treatment" is not sufficient evidence of medical necessity for the procedure or inpatient admission.

Conservative treatment documentation should include:

Physical Therapy Occupational Therapy Joint Injections/Epidural Injections Anti-inflammatory/Analgesic medications Assistive device use Activity modification Exercise

CORPECTOMY CODES 63081 AND 63090Must document % of vertebral body resected

Cervical Spine=1/2

Lumbar Spine =1/3

63047 AND 63048 FOR L4,L5 PARTIAL LAMINECTOMIES, FACETECTOMIES, FORAMINOTOMIES

Documentation to include that compression was noted on both individual nerve roots, that decompression was performed of both nerve roots, that each nerve root was visualized and that nerve roots were free of compression at conclusion of procedure

OSTEOTOMY CODES 22214Documentation must describe actual Osteotomy including

resection of the Supra-spinous ligament, Intra-spinous ligament, ligamentum flavum, and superior and inferior articular processes

TAKING OFF OSTEOPHYTES DOES NOT CONSTITUTE AN OSTEOTOMY

SURGERY REIMBURSEMENT SHEET

CCI SPINE EDITS

E&M POCKET GUIDE

ICD-9/ICD-10 CODE CROSSWALKER

ICD-10 COMMON SPINE CODES

AUTHORIZATION TEMPLATE LETTER

DENIAL TEMPLATES

SURGERY PRE-AUTHORIZATION TEMPLATE

16

Codes ICA CIGNA BCBS HUMANA MEDICARE UNITED AETNA

20930

20931

20937

20938

20975

22214

22216

22551

22552

22554

22558

22585

22600

22612

22614

22630

22632

22633

22634

22830

22840

22842

22843

22844

22845

22846

22847

22850

22852

22853

22854

22855

22859

62351

63012

63030

63035

63042

63047

63048

63075

63076

63077

63078

63081

63082

63090

63091

63267

63655

63660

63685

63688

63700

63702

69990

95972

CORRECT CODING INITIATIVE EDITS

CODES

20930 none

20931 none

20936 none

20937 none

20938 none

20975 69990 (0)

22214 63030 (1) 63047 (1) 69990 (0)

22216 none

22551 22554 (1) 22585 (1) 63075 (1) 63076 (1) 63077 (1) 69990(0)

22552 none

22554 22552 (1) 22830 (1) 63076 (1) 69990 (0)

22558 22634 (1) 22830 (1) 69990 (0)

22585 none

22600 22830 (1) 69990 (0)

22612 22630 (9) 22630 (1) 22830 (1) 69990 (0)

22614 none

22630 22558 (1) 22830 (1) 63030 (1) 63042 (1) 63047 (1) 63267(1) 69990(0)

22632 none

22633 22558 (1) 22612 (1) 22630 (1) 22830 (1) 63012 (1) 63030(1) 63042(1) 63047(1) 63267(1) 69990(0)

22634 22830 (1) 63012 (1) 63030 (1) 63047 (1) 63267 (1) 69990(0)

22830 69990 (0)

22840 22843 (1) 22844 (1) 22850 (1) 22852 (1)

22842 22840 (9) 22850 (1) 22852 (1)

22843 22850 (1) 22852 (1)

22844 22850 (1) 22852 (1) 22855 (1)

22845 22850 (1) 22852 (1)

22846 22850 (1) 22852 (1)

22847 22850 (1) 22852 (1)

22850 22554 (1) 22558 (1) 22600 (1) 22612 (9) 22630 (1) 22830(1) 22840(9) 22841(0) 22842(9) 22845(9)

22852 22554 (1) 22558 (1) 22600 (1) 22612 (9) 22630 (1) 22830(1) 22840(9) 22841(0) 22842(9) 22845(9)

22853 ???

22854 ???

22855 22554(1) 22558 (1) 22600 (1) 22612 (1) 22630 (1) 22830(1) 22840(9) 22840(1) 22841(0) 22842(9) 22842(1) 22843(1) 22845(9) 22845(1) 22846(1) 22847(1)

22859 ???

CCI EDITS

63012

63030

(1)

63042

(1)

63048

(9)

69990

(0)

63030

69990

(1)

63035

63042

(9)

63042

63267

(1)

69990

(0)

63047

22612

(9)

22852

(1)

63012

(1)

63030

(1)

63035

(9)

63042

(1)

63267

(9)

69990

(0)

63048

63030

(9)

63075

22552

(1)

22554

(1)

22585

(1)

63077

(1)

69990

(0)

63076

69990

(0)

63077

69990

(0)

63078

69990

(0)

63081

22251

(1)

22254

(9)

22258

(9)

63075

(1)

63082

22554

(9)

63090

22551

(1)

63075

(1)

63077

(1)

63091 none

63267

63012

(1)

63030

(1)

63047

(1)

63655

69990

(0)

63660

63655

(1)

69990

(0)

63685

63655

(9)

63688

(1)

69990

(0)

63688

63685

(0)

69990

(0)

63700

63702

(1)

69990

(0)

63702

69990

(0)

69990

not in

list

95972 none

If a provider submits the two codes of an edit pair for payment for the same beneficiary on the same date of service, the Column 1 code is eligible for payment and the Column 2 code is denied. However, if both codes are clinically appropriate and an appropriate NCCI-associated modifier is used, the codes in both columns are eligible for payment. Supporting documentation must be in the beneficiary’s medical record.•0-(Not Allowed) There are no modifiers associated with NCCI that are allowed to be used with this PTP code pair; there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider.• 1-(Allowed) The modifiers associated with NCCI are allowed with this PTP code pair when appropriate.• 9-(Not Applicable) This indicator means that an NCCI edit does not apply to this PTP code pair. The edit for this PTP code pair was deleted retroactively.

17

E&M 1997 History Medical Decision (2 OF 3)

CC DX / OPTIONS ( USE AS A GUIDE ONLY)

HPI □Brief (1-3=PF/EPF) □Extend(4+= DET/COMP) □Minimal (minor worsening-improved= SF)

□Location □Duration □Limited (estab worsening=low com)

□Quality □Timing □Moderate (new-no add'l work-up=mod com)

□Severity □Context □Extensive ( new- add'l work-up=high com)

□Mod Factors □Assoc S&S DATA REVIEW

ROS (NONE/1=PF/EPF)

(2-9= DETAILED) ( 10+ = COMP) □Minimal ((none/1=Straightforward)

□Cons □MS □Limited (2 = low complexity)

□Eyes □Int G □Moderate (3 = mod complexity)

□Ent □Neur □Extensive (4+ = high complexity

□Card □Psy RISK

□Resp □Endo □Minimal ( straightforward)

□GI □Hem / Lym □Limited (low complexity)

□GU □All / Imm □Moderate (moderate complexity)

Past Hx (0=PF/EPF) ( 1=DETAIL)(3=COMP) □Extensive ( high complexity)

DATA REVIEW

Review/order tests 7xxxx, 8xxxx, 9xxxx(1pt each) Discuss tests with performing MD(1pt) Personally review images (2pts) Obtains records or history from another(1pt) Review/summarize records or history (2pts)

Fam Hx Soc Hx

Medical Decision Making: Risk(Choose highest

level in any of

the 3)

Problem Test

Ordered

Treatment

Selected

Minimal Minor Lab, X-Ray Bedrest

Low >1 Minor

Acute Minor

Chronic Stable

Minor Ox

Blood Gas

OTC Meds

PT/OT

Moderate >2 Minor

Acute Moderate

Deep Dx

LP

Elective Sx Tx

Rx Drugs

High Severe Worsen

Acute Neuro

Discography

CV Imaging

Major Sx

Emergent Sx

HNP

HNP WITH RADICULOPATHY

HNP WITH MYELOPATHY DDD

CERVICAL UNSPECIFIED M 50.20 M 50.10 M 50.00 M 50.30

CERVICAL HIGH M 50.21 M 50.11 M 50.01 M 50.31

CERVICAL MID

C4-5 M 50.221 C5-6 M 50.222 C6-7 M 50.223

C4-5 M 50.121 C5-6 M 50.122 C6-7 M 50.123

C4-5 M 50.021 C5-6 M 50.022 C6-7 M 50.023

C4-5 M 50.321 C5-6 M 50.322 C6-7 M 50.323

CERVICAL THORACIC M 50.23 M 50.13 M 50.03 M 50.33

THORACIC M 51.24 M 51.14 M 51.04 M 51.34

THORACOLUMBAR M 51.25 M 51.15 M 51.05 M 51.35

LUMBAR M 51.26 M 51.16 M 51.06 M 51.36

LUMBOSACRAL M 51.27 M 51.17 M 51.07 M 51.37

OTHER

MENINGOCELE SEROMA T88.8XXA

LAC DUR PRO G97.41 INFECTED SEROMA T81.4XXA

CSF LEAK G96.0 POST-OP INFECTION T81X4XXA

TEAR G96.11 PAIN ORTHO DEV T84.84XA

OTHER G96.19 PAIN NEURO DEV T85.84XA

HEMATOMA OPLL C SPINE M67.88

DEEP M96.830 COMPRESSION FX (LUMBAR 1-5#) S32.__0A

SKIN/SUBQ L76.22

COMP FX (THOR 1-5#) (T6=5,T7,8=6, T9,10=7, T11,12=8 S22.0__0A

PSEUDARTHROSIS M96.0

RADICULOPATHY STENOSIS SPONDYLOLISTHESIS ACQUIRED

SPONDYLOLYSIS IDIOPATHIC SCOLIOSIS

SPONDYLOSIS SPONDYLOSIS WITH RADICULOPATHY

SPONDYLOSIS WITH MYELOPATHY

UNSPEC INFLAM ARTHROPATHY

OCC THRU C2 M 54.11 M 48.01 N/A M 43.01 N/A

CERVICAL M 54.12 M 48.02 M 43.12 M 43.02 M 41.22 M47.812 M47.22 M47.12 M46.92

CERVICOTHORACIC M 54.13 M 48.03 M 43.13 M 43.03 M 41.23

THORACIC M 54.14 N/A M 43.14 M 43.04 M 41.24 M47.814 M47.24 M47.14 M46.94

THORACOLUMBAR M 54.15 N/A M 43.15 M 43.05 M 41.25

LUMBAR M 54.16 M 48.06 M 43.16 M 43.06 M 41.26 M47.816 M47.26 M47.16 M46.96

LUMBOSACRAL M 54.17 M 48.07 M 43.17 M 43.07 N/A

SACRAL COCCYGEAL N/A N/A M 43.18 M 43.08 N/A

MULTIPLE N/A N/A M 43.19 N/A N/A

DIAGNOSIS

CERVICAL LUMBAR THORACIC OTHER SPINE

M50.21 CERVICAL HIGH HNP

M50.221 C4-5,M50.222 C5-6,M50.223

C6-7 HNP

M51.25 HNP THORACOLUMBAR M51.24 HNP M54.2 PAIN CERVICAL

M50.22 HNP MID M51.26 HNP LUMBAR M51.14 HNP W RADICULOPATHY M54.6 PAIN THORACIC

M50.23 HNP LOW M51.27 HNP LUMBOSACRAL M51.04 HNP W MYELOPATHY M54.5 PAIN LUMBAR

M50.11 HNP W RADICULOPATHY HIGH M51.16 HNP W RADIC LUMBAR M54.14 RADICULOPATHY M54.30 SCIATICA UNSPECIFIED

M50.121 C4-5, M50.122 C5-6, M50.123

C6-7 HNP WITH RADICULOPATHY

M51.17 HNP W RADIC LUMBOSACRAL M51.34 DDD M54.31 SCIATICA RIGHT

M50.13 HNP W RADICULOPATHY

CERVICO/THORACIC

M51.06 HNP W MYELO LUMBAR M43.05 IDIOPATHIC THORACIC SCOLI M54.32 SCIATICA LEFT

M50.01 HNP W MYELOPATHY HIGH M54.16 RADICULOPATHY LUMBAR M40.204 THORACIC KYPHOSIS UNSP M54.40 SCIATICA W BACK PAIN

M50.021 C4-5, M50.022 C5-6, 50.023 C6-

7 HNP W MYELOPATHY

M54.17 RADICULOPATHY LUMBSAC M54.41 SCIATICA W BACK PAIN RT

M50.03 HNP W MYELOPATHY

CERVICO/THORACIC

M48.06 STENOSIS LUMBAR S22.0__0A COMP FX( THOR 1- 5 #) M54.42 SCIATICA W BACK PAIN LT

M54.12 RADICULOPATHY CERVICAL M48.07 STENOSIS LUMBOSACRAL ( T6=5,T7,8=6,T9,10=7,T11,12=8) M96.0 PSEUDARTHROSIS

M54.13 RADICULOPATHY CT REGION M51.35 DDD THORACOLUMBAR M53.3 COCCYDYNIA

M48.02 STENOSIS CERVICAL M51.36 DDD LUMBAR OTHER MISC M48.9 SPONDYLOPATHY (DISH) UNSP

M48.03 STENOSIS CT REGION M51.37 DDD LUMBOSACRAL G56.01 CARPAL TUNNEL SYN RT UE M81.0 OSTEOPOROSIS AGE WO PATFX

M47.812 SPONDYLOSIS (FACET SYND) M41.25 IDIO THORACOLUMB SCOLI G56.02 CARPAL TUNNEL SYN LT UE M81.8 OSTEOPOROSIS OTH WO PATFX

M47.22 SPONDYLOSIS W RADIC (FS) M41.26 IDIO LUMBAR SCOLIOSIS M40.61 TROCHANTERIC BURSITIS RT M96.1 POST LAMINECTOMY SYND

M47.12 SPONDYLOSIS W MYELO (FS) M43.16 SPONDYLOLISTHESIS LUMB M70.62 TROCHANTERIC BURSITIS LT M96.3 KYPHOSIS POST LAMI

M46.92 UNSP INFLAM ARTHROP (FC) M43.17 SPONDYLOLISTHESIS MULTI 657.01 LESION SCIATIC NERVE RT M67.88 OPLL CERVICAL SPINE

M50.31 DDD HIGH M47.816 SPONDYLOSIS (FACET SYND) 657.02 LESION SCIATIC NERVE LT S13.4XXA SPRAIN CERVICAL SPINE

M50.321 C4-5, M50.322 C5-6, M50.323

C6-7 DDD

M47.26 SPONDYLOSIS W RADIC (FS) G56.21 LESION ULNAR NERVE RIGHT S33.5XXA SPRAIN LUMBAR

M50.33 DDD CERVICO/THORACIC M47.16 SPONDYLOSIS W MYELO (FS) G56.22 LESION ULNAR NERVE LEFT

M43.12 SPONDYLOLISTHESIS AQU M46.96 UNSP INFLAM ARTHROP (FC)

S32.0__0A COMP FX (LUM 1-5 #)

18

ICD-10 Coordination and Maintenance Committee◦ The ICD-10 Coordination and Maintenance Committee (C&M) is a Federal interdepartmental

committee comprised of representatives from the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS).

◦ The committee is responsible for approving coding changes, developing errata, addenda and other modifications. Requests for coding changes are submitted to the committee for discussion at either the Spring or Fall C&M meeting.

Coordination and Maintenance Committee Meetings◦ The Committee provides a public forum to discuss proposed changes to ICD-10. The first day of

the meeting is devoted to procedure code issues and is led by CMS. The second day is devoted to diagnosis code issues and is led by CDC. Tentative agendas for the meetings are posted one month in advance of the scheduled meetings.

CMS ICD-10-CM/PCS Coordination and Maintenance Committee meeting occurred on March 7 and 18. Next meeting in September

ICD-10-PCS Procedure Code Revisions◦ The request for a procedure code change should be submitted at least two months prior to the

C&M meeting. The request should include the following in a background paper: Issue: Describe the procedure and why current ICD-10-PCS codes do not adequately capture the procedure

Background: provide detailed background information describing the procedure, patients on whom the procedure is performed, outcomes, any complications, and other relevant information. If this procedure is a significantly different means of performing a procedure that is already described in ICD-10-PCS, this difference should be clearly described. The manner in which the procedure is currently coded should be described along with information from the requestor on why they believe the current code is not appropriate.

Options: Possible new or revised code titles should then be recommended.

http://www.wedionline.org/icd-10/default.aspx

19

The ICD-10 code lookup tool: https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx

ICD-10 coding resources for Providers: https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

For specific coding questions: Specific coding questions should be submitted to the American Hospital Association (the official US clearinghouse on medical coding) via http://www.codingclinicadvisor.com/

AHIMA is providing coding advice for a fee through their Code Check service. You can learn more information at this link: http://www.ahima.org/topics/codecheck

Updated codes sets may be obtained free of charge at the following websites:

ICD-10 CM: https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html

ICD-10 PCS: https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html

ICD-10 CM Guidelines, maybe found at the following website:

http://www.cdc.gov/nchs/data/icd/10cmguidelines_2016_Final.pdf

Please refer to the following FAQ information on GEMs:

https://www.cms.gov/medicare/coding/icd10/downloads/gems-crosswalksbasicfaq.pdf

For questions about Claims Processing and Payment or Local Coverage Determinations contact your Medicare Administrative Contractor (MAC) for guidance. You can find the list of MACs at this link:https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-Provider-Contact-Table.pdf

For questions about National Coverage Determinations: https://www.cms.gov/Medicare/Coverage/InfoExchange/contactus.html

For requests to update the ICD-10-CM codes, please note The Centers for Disease Control and Prevention (CDC) is responsible for the development and maintenance of ICD-10-CM. ICD-10-CM comments can be sent to to: Donna Pickett, CDC [email protected]

URGENT FAX

SURGICAL PREAUTHORIZATION REQUEST

To: Insurance Carrier: ____________________________ Fax: _______________

From: _________________________________________

Phone: ________________________________________ Fax: _______________

Re: Patient: ____________________________________________

Ins. I.D. # __________________________________________

We are hereby writing to request your review and handling of the preauthorization for the

below referenced procedures for the referenced patient noted above. This patient has been

seen and evaluated by our physician _______________________, and as a result of that

evaluation the physician has recommended the following procedure(s).

Procedure CPT code ICD 9/ ICD 10 code

We hereby request that your medical review area or other pertinent authorization department

review the foregoing and provide us with the following:

1. Preauthorization # for this procedure with listing of all authorized codes

Supporting documentation is attached which demonstrates medical necessity for the

procedures noted above.

If you require further information in order to process this request, please contact the

representative indicated above.

Name of Authorizing Agent for Carrier: ________________________

Telephone # for Authorizing Agent: ___________________________

Preauthorization #: _________________________________________

Comments or Requirements: _________________________________

_________________________________________________________

Appeal Letter for Modifier 59

[Date]

Attn: _____________________________

Provider Appeals Department

[Address]

[City, State, ZIP Code]

Re: Denial of CPT code with modifier 59

Insured/Plan Member:

Health Insurer Identification Number:

Group Number:

Patient Name:

Claim Number:

Claim Date:

Dear [Health insurer]:

This letter documents our use of CPT modifier 59 reported with [procedure name] CPT

[code] to indicate that the services are not typically performed together and should be

separately reimbursed.

Developed by the American Medical Association modifier 59 identifying services not

typically performed together. According to guidelines, modifier 59 is appended to

indicate that under particular circumstances a physician performed a distinct and

independent procedure from other services performed on the same day. CPT states:

“Modifier 59 is used to identify procedures/services that are not normally reported

together, but are appropriate under these circumstances.” [reason procedure or service

was performed.]

Our use of modifier 59 on CPT [list code] is well documented in the patient’s record

(attached) and should be recognized and the code paid.

We are requesting review by medical staff to circumvent the computer generated code

edit resulting in this bundling edit.

https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx

https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

http://www.codingclinicadvisor.com/

http://www.ahima.org/topics/codecheck

https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html

https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html

http://www.cdc.gov/nchs/data/icd/10cmguidelines_2016_Final.pdf

https://www.cms.gov/medicare/coding/icd10/downloads/gems-crosswalksbasicfaq.pdf

https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-Provider-Contact-Table.pdf

https://www.cms.gov/Medicare/Coverage/InfoExchange/contactus.html

mailto:[email protected]

20

March 24, 2017 <Insert insurance company name and address> WE DISAGREE WITH THE AMOUNT DETERMINED FOR THE ABOVE

PROCEDURES BILLED; THEREFORE, A REVIEW IS REQUESTED ON THE

ABOVE PROCEDURE CODES. THE BASIS FOR OUR APPEAL IS AS

FOLLOWS:

The primary procedure paid is the procedure code with the highest allowed

value. In this surgery, the procedure code 22612 has a _______ allowable of

_____. Therefore, we disagree with your allowing procedure code 63047 as

the primary procedure code since its allowable is $_____.

The procedure code 63030. 63030-50 represents a bilateral procedure . On

level L4-5 a bilateral discectomy was performed. The code 63030 is for a

unilateral procedure. Therefore, the bilateral portion of this procedure should

be paid at 50% of the allowed amount. You will find enclosed the AMA CPT

Guidelines for bilateral procedure on 63030.

The following calculation based on coding and reimbursement guidelines according to

our contract with _______ is as follows:

Procedure

Code

<Insurer’s>

Allowable

Multiple %

Procedures

Expected <Insurer’s>

Payment

22612 100%

22614 100%

22614 100%

63047-51 50%

63030-51-59 25%

63030-50-59 10%

22842 100%

20931 100%

Total Payment

Because the original <Insurance name> payment is $___ for the surgeon’s bill, the

additional payment requested is $___ based on the above table based on our contract

guidelines. Please adjust the assistant surgeon’s bill as well.

You will also find a copy of the original claim, operative report and your explanation

of benefits/review.

Sincerely,

<name>

<Practice Administrator/Billing Manager>

October 9, 2015

<Insert Insurance Company name and address>

A REVIEW BY _________ IS REQUESTED ON THE ABOVE

PROCEDURE CODE. THE BASIS FOR OUR APPEAL IS AS FOLLOWS:

The procedure code xxxxx is modifier 51 exempt and should be paid at

100% of its value for each level and billed. Therefore, we are requesting that xxxxx be paid at the allowed value of $xx.

The additional allowable is $xx. The additional payment expected is $xx. Enclosed you will find a copy of the original claim, operative report and your

explanation of benefits/review. Sincerely,

<name> <Office Manager/Billing Manager>

Addendum AA -- Final ASC Covered Surgical Procedures for CY 2016 (Including Surgical Procedures for Which

Payment is Packaged)

CPT codes and descriptions only are copyright 2015 American Medical Association. All Rights Reserved. Applicable

FARS/DFARS Apply. Dental codes (D codes) are copyright 2015 American Dental Association. All Rights Reserved.

HCPCS

Code Short Descriptor

Subject to

Multiple

Procedure

Discounting

Jan 2016

Payment

Indicator

20930 Sp bone algrft morsel add-on N1

20931 Sp bone algrft struct add-on N1

22510 Perq cervicothoracic inject Y G2

22511 Perq lumbosacral injection Y G2

22512 Vertebroplasty addl inject N1

22513 Perq vertebral augmentation Y G2

22514 Perq vertebral augmentation Y G2

22515 Perq vertebral augmentation N1

22551 Neck spine fuse&remov bel c2 Y J8

22554 Neck spine fusion Y J8

22612 Lumbar spine fusion Y G2

22614 Spine fusion extra segment N1

62310 Inject spine cerv/thoracic Y A2

62311 Inject spine lumbar/sacral Y A2

62318 Inject spine w/cath crv/thrc Y A2

62319 Inject spine w/cath lmb/scrl Y A2

63001 Remove spine lamina 1/2 crvl Y G2

63003 Remove spine lamina 1/2 thrc Y G2

63005 Remove spine lamina 1/2 lmbr Y G2

63020 Neck spine disk surgery Y G2

63030 Low back disk surgery Y G2

63042 Laminotomy single lumbar Y G2

63044 Laminotomy addl lumbar N1

63045 Remove spine lamina 1 crvl Y G2

63046 Remove spine lamina 1 thrc Y G2

63047 Remove spine lamina 1 lmbr Y G2

63055 Decompress spinal cord thrc Y G2

63056 Decompress spinal cord lmbr Y G2

63650 Implant neuroelectrodes N J8

63655 Implant neuroelectrodes N J8

63661 Remove spine eltrd perq aray N G2

63662 Remove spine eltrd plate N G2

63663 Revise spine eltrd perq aray N J8

63664 Revise spine eltrd plate N J8

63685 Insrt/redo spine n generator N J8

63688 Revise/remove neuroreceiver N A2

69990 Microsurgery add-on N1

21

Addendum B.-Final OPPS Payment by HCPCS Code for CY 2016

CPT codes and descriptions only are copyright 2015 American Medical Association. All

Rights Reserved. Applicable FARS/DFARS Apply. Dental codes (D codes) are copyright

2015 American Dental Association. All Rights Reserved.

HCPCS Code Short Descriptor SI

22513 Perq vertebral augmentation J1

22514 Perq vertebral augmentation J1

22515 Perq vertebral augmentation N

22551 Neck spine fuse&remov bel c2 J1


22554 Neck spine fusion J1



22585 Additional spinal fusion C

22586 Prescrl fuse w/ instr l5-s1 C

22590 Spine & skull spinal fusion C

22595 Neck spinal fusion C

22600 Neck spine fusion C


22612 Lumbar spine fusion J1




22633 Lumbar spine fusion combined C


22800 Post fusion </6 vert seg C

22802 Post fusion 7-12 vert seg C

22804 Post fusion 13/> vert seg C



22812 Ant fusion 8/> vert seg C

22818 Kyphectomy 1-2 segments C

22819 Kyphectomy 3 or more C

22830 Exploration of spinal fusion C









22848 Insert pelv fixation device C

22849 Reinsert spinal fixation C


22851 Apply spine prosth device N



22856 Cerv artific diskectomy J1

22857 Lumbar artif diskectomy C

22858 Second level cer diskectomy C

22861 Revise cerv artific disc C

22862 Revise lumbar artif disc C

22864 Remove cerv artif disc C

22865 Remove lumb artif disc C

22899 Spine surgery procedure T

63001 Remove spine lamina 1/2 crvl J1

63003 Remove spine lamina 1/2 thrc J1

63005 Remove spine lamina 1/2 lmbr J1

63011 Remove spine lamina 1/2 scrl J1

63012 Remove lamina/facets lumbar J1

63015 Remove spine lamina >2 crvcl J1

63016 Remove spine lamina >2 thrc J1

63017 Remove spine lamina >2 lmbr J1


63030 Low back disk surgery J1

63035 Spinal disk surgery add-on N

63040 Laminotomy single cervical J1

63042 Laminotomy single lumbar J1

63043 Laminotomy addl cervical N

63044 Laminotomy addl lumbar N

63045 Remove spine lamina 1 crvl J1

63046 Remove spine lamina 1 thrc J1

63047 Remove spine lamina 1 lmbr J1

63048 Remove spinal lamina add-on N

63050 Cervical laminoplsty 2/> seg C

63051 C-laminoplasty w/graft/plate C


63056 Decompress spinal cord lmbr J1

63057 Decompress spine cord add-on N


63066 Decompress spine cord add-on N


63076 Neck spine disk surgery N

63077 Spine disk surgery thorax C

63078 Spine disk surgery thorax C

63081 Remove vert body dcmprn crvl C

63082 Remove vertebral body add-on C

63085 Remove vert body dcmprn thrc C


63087 Remov vertbr dcmprn thrclmbr C


63090 Remove vert body dcmprn lmbr C


69990 Microsurgery add-on N

Documents

North American Spine Society CODING UPDATE 2017 · 1 North American Spine Society CODING UPDATE 2017 22000 Codes Musculoskeletal Section Gregory J. Przybylski, MD 22000 Series I&D