The increase in spinal fusion procedures during the past decade has drawn scrutiny from the Centers for Medicare and Medicaid Services and third party payers, resulting in coverage limitations for some of these procedures. Recent CMS coverage decisions for established, concurrent spinal procedures will be examined in this Coding Corner.
Coding for Decompression and Arthrodesis for Spondylolisthesis
A common procedure for lumbar spondylolisthesis involves decompression of the nerve roots and a lumbar arthrodesis. A variety of procedures exist for decompression including laminectomy for lateral recess stenosis (63047) or for Gill fragment removal (63012), and discectomy for posterolateral herniation (63030), for far lateral disc herniation (63056), or for re-exploration of a disc herniation (63042).
Several years ago, the Current Procedural Terminology Editorial Panel approved an editorial change to posterior lumbar interbody arthrodesis (22630) that includes laminectomy and discectomy work other than that needed for decompression. However, the National Correct Coding Initiative of the CMS excluded coding of 22630 concurrently with the decompression codes under ordinary circumstances.
The vignette describing posterior lumbar interbody arthrodesis identifies a patient with mechanical back pain after prior discectomy and failed posterolateral fusion who undergoes a laminectomy, discectomy and interbody arthrodesis. Since the described patient does not have radiculopathy, a decompression above and beyond what is required to perform the posterior interbody fusion is not included in the vignette. However, the vignette does describe mobilization of nerve roots and dural sac as well as dissection of scar tissue necessary to perform the fusion. It may be difficult when coding to differentiate the incidental decompression that occurs during the laminectomy and discectomy approach for the interbody fusion from the additional decompression that may be warranted because of neurological symptoms from compressive lesions. Correct coding for interbody fusion is further complicated when a unilateral approach using a transforaminal technique is performed because code 22630 describes a bilateral procedure. In either instance, if a decompression procedure is performed beyond what is required for the interbody exposure, then the decompression should be appended with the -59 modifier (unusual procedural services) to acknowledge this as separately identifiable additional work, and it is critical for the neurosurgeon to document the separate location of compression that is being treated.
Another recent limitation imposed by the CMS is for concurrent performance of a posterior arthrodesis and a posterior lumbar interbody fusion. The authors of the lumbar fusion guidelines, published in June 2005, concluded that complications and costs were higher and without an observed benefit when a posterior fusion is performed in addition to an interbody fusion. This year, CMS payment policy precludes payment for a posterior fusion when an interbody fusion is performed. The various surgical societies representing spinal surgery are reviewing the guidelines and their implications before preparing a response to the CMS decision.
Coding for Revision Spinal Surgery
Additional difficulties in proper coding are encountered when revision spinal surgery is performed. For example, a revision of a prior fusion may include procedures such as exploration of a fusion (22830), removal (22852), reinsertion (22849), or placement of spinal instrumentation (22840-22844), and performance of a fusion at the same or adjacent levels (22612, 22614, 22630, 22632). The CMS has used National Correct Coding Initiative edits for years to preclude payment for an exploration of fusion with arthrodesis, despite introductory language in CPT that specifically identifies arthrodesis and instrumentation as separate physician work. Although an exploration of fusion and arthrodesis at the same level should be considered inclusive, arthrodesis at adjacent levels is separately identifiable and the arthrodesis code should be appended with the -59 modifier. If spinal instrumentation is removed and replaced at the same levels, only code 22849 should be used, rather than a removal code and an insertion code.
When spinal instrumentation is removed and then replaced with instrumentation extended to additional levels, one must balance the lesser work of replacing fixation in sites that have been prepared previously with the new work of exposing and placing fixation at new levels. An insertion code that describes the entire span of instrumentation (both revised and new) would reflect the physician work under most circumstances because the work of removal and replacement at an individual level is similar to work of preparation and insertion at a new level. The neurosurgeon should be aware that the removal and reinsertion of instrumentation codes are 90-day global codes to which the multiple procedure modifier -51 applies, whereas the insertion codes are ZZZ global codes and are not subject to a 50 percent payment reduction when used with other stand-alone codes.
The area of spinal coding and reimbursement is frequently changing. Therefore, it behooves neurosurgeons to keep abreast of these changes annually.
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, and he chairs and instructs coding courses for the AANS and the North American Spine Society.