| The CMS had been very receptive to review and analysis of evidence by medical specialty societies and to thier recommendations concerning proposed edits. |
Although Current Procedural Terminology describes physician services that are bundled together, the CMS has used an additional system, the Correct Coding Initiative or CCI, to identify bundled services. Through a contract with one of its regional carriers, the CMS publishes a quarterly update of code pairings which are considered inclusive of one another. Although this process formerly occurred in the absence of medical specialty society input, for several years the CMS has requested physicians’ advice on proposed edits to improve the accuracy of these edits.
At the end of 2005, a proposed edit was sent to specialty societies concerning codes 22612 and 22630. Although the CMS did not submit a rationale for the proposed edit, societies were asked to consider the edit and offer medical reasons for modification, if appropriate. However, the proposed edits were developed shortly after the publication of the lumbar fusion guidelines. Although the guidelines described the evidence against performing a concurrent anterior lumbar interbody fusion with a posterior arthrodesis, the scientific evidence reviewed did not address a posterior lumbar interbody fusion and a concurrent posterior or posterolateral arthrodesis. Despite comments submitted by several societies describing the separately identifiable physician services between 22612 and 22630, on April 1 the CMS implemented an edit that precluded concurrent coding of these procedures.
After implementation of the edit, the CMS received numerous correspondences concerning the edit. The CMS agreed to reconsider the implemented edit if additional documentation were submitted to justify medical necessity for performing both procedures at the same level. Multiple specialty societies participated in this effort, among them the AANS, the Congress of Neurological Surgeons and the North American Spine Society. The AANS, CNS and NASS produced a document requesting reconsideration of the edit and provided the medical rationale for the necessity of performing both procedures under certain circumstances.
In July, the CMS responded favorably to the request and agreed to remove the CCI edit beginning Oct. 1. In addition, the CMS agreed to retroactively allow concurrent use of codes 22612 and 22630 and recommended that after Oct. 1 surgeons resubmit claims for which the code pairing had been denied.
In comparison to the former CCI process in which the predominant rationale for developing edits focused on overlapping physician work, there seems to be a trend toward examining the medical necessity and medical evidence for performing concurrent procedures. Previously, specialty society responses to the CMS concerning proposed edits predominantly addressed the degree of overlapping physician work when two procedures were compared. However, in this circumstance, the distinction between the physician work of a posterolateral arthrodesis and a posterior lumbar interbody fusion was insufficient to prevent the implementation of the proposed edit. This suggests that the governmental and private insurer efforts in developing performance measures and standards are likely to include payment policies and coverage decisions that take into account the published scientific evidence regarding surgical procedures.
While the CMS appears to be moving beyond the issue of overlapping physician work in the development of CCI edits and toward evidence-based examination of the medical necessity of surgical procedures, it also has been very receptive to review and analysis of evidence by medical specialty societies and to their recommendations concerning proposed edits. Although this particular example resulted in denial of payment for six months, the correction was made retroactive, allowing for resubmission of claims beginning in Oct. 1.
Gregory J. Przybylski, MD, is professor and director of neurosurgery at JFK Medical Center in Edison, N.J. He is chair of the AANS/CNS Coding and Reimbursement Committee and a member of the CMS Practicing Physicians Advisory Council. He chairs and instructs coding courses for the AANS and the North American Spine Society.