Laminectomy and Interbody Fusion Confusion
With this edition of Coding Clarity, we return to nuts and bolts coding questions. Actually, this edition is a bit of catch up, since I am going to review a coding change that was made one year ago. I will try to explain some of the back story for this change, and then, also mention a new modification to use for the -59 modifier that will be coming our way in the future.
Proper Codes for Laminectomy and Interbody Fusion
Consider a patient with a degenerative spondylolisthesis at the lumbar 4-5 level that you are going to do a decompression and stabilization on. You chose to do an interbody fusion, with a laminectomy bilaterally for the patient’s stenosis. You will use bone graft and instrumentation, but we will not focus on those codes here. In your procedure, you resect one of the facet joints and do a wide decompression of the neural foramina, giving you access to the disc space so that you may do your interbody fusion. But, since the patient has severe bilateral stenosis, you also resect the remainder of the lamina and decompress the contralateral neural foramina. The code for an interbody fusion is 22630 (22633 if you do a posterolateral fusion as well), and the code for the laminectomy is 63047.
Prior to January 2015, when a surgeon performed this procedure, we taught you should report the interbody fusion and the decompression, since the interbody fusion bony work is less that what would be required for doing the interbody fusion and a lumbar laminectomy. The CPT descriptor for interbody fusion states as much, noting that the bone work in performing 22630 “including laminectomy and/or discectomy to prepare interspace (other than for decompression)” is included in the procedure.
There are two modifiers that are relevant to this discussion, -51 and -59. Recall that modifiers are used to append to base codes to give more information about the procedure being performed. Both of these modifiers are “same day” modifiers, meaning that they apply to bills being generated on the same calendar day, usually during the same surgery.
-51 is the multiple procedure modifier. It is applied when you are doing more than one procedure on the same day of service. So, for instance, you do an anterior cervical decompression and fusion and a posterior cervical fusion during the same operative setting. You would bill the ACDF (22551) and the posterior cervical fusion (22600); the 22600 would take a -51 modifier. You put the -51 modifier on the lower valued code.
Duplicate Work During Pre-operative and Post-operative Care
Why? Because of the work entailed in the pre-operative and post-operative care of the patient is being duplicated. Both the codes (22551 and 22600) are standalone codes, with pre-op work, intra-op work and a 90-day global. You need to note that the -51 accomplishes this.
-59 is for distinct procedures done in the same operative setting. Usually, this code is applied when the work would otherwise be considered to be bundled into another procedure. Hence, -59 “unbundles” the work.
An easy example is placement of a ventriculostomy when you are doing an aneurysm surgery. If you place the ventric through the same craniotomy where you are doing your primary surgery, you do not report it. That is considered part of the work in your craniotomy. However, if you do a separate burr hole and place the ventric into the contralateral side, that additional work should be captured and use of a -59 modifier is appropriate.
Reporting a Laminectomy
With that background, let’s get back to the case. You do an interbody fusion and a laminectomy at the same level. The laminectomy is considerably more work than you would have needed to just do the interbody fusion. How do you report the work of the laminectomy?
In the American Association of Neurological Surgeons (AANS) coding courses, up until 2015, we taught that you should report the laminectomy (63047) by adding a -59 modifier to the code. The rationale was that the laminectomy is additional work and is being performed on a separate anatomic site (nervous system), as opposed to the interbody fusion (musculoskeletal system). While the Centers for Medicare and Medicaid Services (CMS) and other private insurers may deny this, it is appropriate to appeal, and the coding convention follows CPT terminology.
The rationale for this convention goes back to when the codes were being created and when one specialty would routinely perform the decompression portion of the procedure and a second specialty would perform the arthrodesis portion of the procedure. We recently valued the combined interbody/posterolateral fusion code (22633) and re-assessed the interbody (22630) codes through the RBRVS Update Committee process; this assumption was built into how we valued the codes.
However, this changed with a National Correct Coding Initiative (NCCI) edit that was published on Jan. 1, 2015. The edit noted that decompression codes (specifically 63042 and 63047) cannot be reported at the same level as interbody fusion codes (22630 or 22633) in Medicare patients. If you report the laminectomy with a -59, it is assumed that the laminectomy is being done at a different level, and your documentation will need to cover this.
We have been routinely teaching this new coding change at the AANS coding courses, and I published this in the Spine Section newsletter, but I did not report it in this column because I was hopeful that it would be overturned. Your Washington Committee Coding and Reimbursement team put a ton of work into this.
A coding column from another spine organization originally propagated this error. We had that column corrected and an errata published. We reached out to the NCCI team and made our case. We reviewed our literature with them, and they acknowledged our concerns. Finally, a group of representative spine surgeons reviewed the matter with both NCCI and the CMS.
CMS chose to not overturn the edit.
So, for a Medicare patient, when you do a laminectomy at the same level that you do an interbody fusion, you do not get to report the laminectomy.
Four New Modifiers
Part of this effort may arise from CMS believing that the -59 modifier may be inappropriately used in some settings. Due to the concerns over abuse of the modifier, CMS is introducing four new modifiers that will replace -59. To my knowledge, these modifiers are not in use at present, but may be in the future. Your Medicare carrier may require them at some point.
There will be four modifiers that replace -59:
- XE Separate Encounter;
- XP Separate Provider;
- XS Separate Structure; and
- XU Unusual or Non-Overlapping Service.
At present, these are under development — the last word from CMS is to continue using -59. In a future column, however, we may need to review these modifiers in detail if their use becomes mandatory.
All of these issues and much more are reviewed during the Managing Coding courses offered by the AANS. There are also resources available including the AANS Guide to Coding, the E&M Reference Card and other online content. The AANS remains dedicated to providing accurate, timely coding and reimbursement education and support to members. If you have any questions or concerns, please do not hesitate to contact me or any member of the Coding and Reimbursement Committee for help.
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