# MILD procedure coding



## sarthur (Apr 10, 2017)

Is the correct CPT code for the MILD (minimally invasive lumbar decompression) procedure still 0275T? I was reading through old postings on here that stated using 63030 and 63035 is inappropriate but I wanted to see if anyone had experience coding for this procedure currently. If it is still 0275T my understanding of the code description is that you would not report imaging guidance with it separately. Is that accurate? 

Also, the provider wanting to perform this procedure is based in Colorado (under Novitas Medicare jurisdiction) and the Vertos rep told the physician that CMS recently approved this procedure but I can't find anything confirming that is the case. Does anyone have experience with that or can point me to something in writing one way or the other?


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## dwaldman (Apr 22, 2017)

0275T is for a percutaneous approach
62287 is for needle based approach for removal of disc material
62380 is an endoscopic approach for laminotomy/discectomy
63030 is an open approach/direct visualization with laminotomy with discectomy for a herniated disc
63047 is an open approach/direct visualization for laminectomy/foraminotomy for spinal stenosis

0275T 
Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar 

Excludes Laminotomy/hemilaminectomy by open and endoscopically assisted approach (63020-63035) 
Excludes Percutaneous decompression of nucleus pulposus of intervertebral disc by needle-based technique (62287) 

For non-needle based technique for percutaneous decompression of nucleus pulposus of intervertebral disc, see 0274T, 0275T) 
__________________________________________________________________________________________
AMA CPT CHANGES 2017 (ALSO FOUND IN AMA CPT MANUAL PROFESSIONAL EDITION 2017)

Endoscopic Decompression of Neural Elements and/or Excision of Herniated Intervertebral Discs  
Definitions For purposes of CPT coding, the following definitions of approach and visualization apply. 

The primary approach and visualization define the service, whether another method is incidentally applied. Surgical services are presumed open, unless otherwise specified. Percutaneous: Image-guided procedures (eg, computer tomography [CT] or fluoroscopy) performed with indirect visualization of the spine without the use of any device that allows visualization through a surgical incision. 

Endoscopic: Spinal procedures performed with continuous direct visualization of the spine through an endoscope. Open: Spinal procedures performed with continuous direct visualization of the spine through a surgical opening. 

Indirect visualization: Image-guided (eg, CT or fluoroscopy), not light-based visualization. 

Direct visualization: Light-based visualization; can be performed by eye, or with surgical loupes, microscope, or endoscope. 

(For the techniques of microsurgery and/or use of microscope, use 69990) 
(For percutaneous decompression, see 62287, 0274T, 0275T) ● 

62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar 

Rationale 
In accordance with the establishment of new definitions of key terms and operative approaches (including percutaneous, endoscopic, open, indirect visualization, and direct visualization) added to the code set for spinal procedures, a new subsection, heading, and code have been established for endoscopic decompression of neural elements and/or excision of herniated intervertebral disc procedures. The new definitions have also been included as guidelines under this new subsection. To align with the new definitions, a new subsection and heading were necessary to encompass the new endoscopic decompression procedure. Code 62380 has been established to report a lumbar endoscopic decompression procedure and includes laminotomy, partial facetectomy, foraminotomy, discectomy, and/or excision of herniated intervertebral disc for one interspace. Parenthetical notes have been added referencing codes 63030 and 63056 if an open procedure is performed, as described by the new definitions that distinguish open and endoscopic procedures. Modifier 50 for bilateral procedures should be appended to 62380 if a bilateral procedure is performed. In accordance with the establishment of the Endoscopic subsection and new code 62380, the percutaneous codes 62287, 0274T, and 0275T have been editorially revised by removing references to “endoscopic,” as the new definitions distinguish percutaneous and endoscopic procedures. Refer to the codebook and the Rationale for codes 62287, 0274T, and 0275T for a full discussion of these changes. Refer to the codebook and the Rationale for the new definitionsin the InjectionDrainage, or Aspiration heading in the Spine and Spinal Cord subsection for a full discussion of the changes.
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I am not aware of CMS covering this procedure other than for a clinical study. They implemented a national coverage determination policy that states that this percutaneous approach is not covered unless there is a specific clinical study being performed:

https://www.cms.gov/medicare-covera...58&ncdver=1&DocID=150.13&bc=gAAAAAgAAAAAAA==&


National Coverage Determination (NCD) for Percutaneous image-guided lumbar decompression for lumbar spinal stenosis (150.13)

Number 
100-3 
Manual Section Number 
150.13 
Manual Section Title 
Percutaneous image-guided lumbar decompression for lumbar spinal stenosis 

Version Number 
1 
Effective Date of this Version 
1/9/2014 
Implementation Date 
10/6/2014 

Benefit Category 
Outpatient Hospital Services Incident to a Physician's Service 
Physicians' Services 

Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description 
A.*** General
PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. This is a procedure proposed as a treatment for symptomatic LSS unresponsive to conservative therapy. This procedure is generally described as a non-invasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum. The procedure is performed under x-ray guidance (e.g., fluoroscopic, CT) with the assistance of contrast media to identify and monitor the compressed area via epiduragram.

Indications and Limitations of Coverage 
B.*** Nationally Covered Indications
Effective for services performed on or after January 09, 2014, the Centers for Medicare & Medicaid Services (CMS) has determined that PILD will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) through Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study that meets the criteria below.
CMS has a particular interest in improved beneficiary function and quality of life, specific characteristics that identify patients who may benefit from the procedure, and the duration of benefit. A clinical study seeking Medicare payment for PILD for LSS must address one or more aspects of the following questions in a prospective, randomized, controlled design using current validated and reliable measurement instruments and clinically appropriate comparator treatments, including appropriate medical or surgical interventions or a sham controlled arm, for patients randomized to the non-PILD group.
The study protocol must specify a statistical analysis and a minimum length of patient follow up time that evaluates the effect of beneficiary characteristics on patient health outcomes as well as the duration of benefit.
Does PILD provide a clinically meaningful improvement of function and/or quality of life in Medicare beneficiaries with LSS compared to other treatments?
Does PILD provide clinically meaningful reduction in pain in Medicare beneficiaries with LSS compared to other treatments?
Does PILD affect the overall clinical management of LSS and decision making, including use of other medical treatments or services, compared to other treatments?
These studies must be designed so that the contribution of treatments in addition to the procedure under study are either controlled for or analyzed in such a way as to determine their impact.
The principal purpose of the research study is to test whether a particular intervention potentially improves the participants’ health outcomes.
The research study is well supported by available scientific and medical information or it is intended to clarify or establish the health outcomes of interventions already in common clinical use.
The research study does not unjustifiably duplicate existing studies.
The research study design is appropriate to answer the research question being asked in the study.
The research study is sponsored by an organization or individual capable of executing the proposed study successfully.
The research study is in compliance with all applicable Federal regulations concerning the protection of human subjects found at 45 CFR Part 46. If a study is regulated by the Food and Drug Administration (FDA), it must be in compliance with 21 CFR parts 50 and 56.
All aspects of the research study are conducted according to appropriate standards of scientific integrity (see http://www.icmje.org).
The research study has a written protocol that clearly addresses, or incorporates by reference, the standards listed here as Medicare requirements for CED coverage.
The clinical research study is not designed to exclusively test toxicity or disease pathophysiology in healthy individuals. Trials of all medical technologies measuring therapeutic outcomes as one of the objectives meet this standard only if the disease or condition being studied is life threatening as defined in 21 CFR § 312.81(a) and the patient has no other viable treatment options.
The clinical research study is registered on the ClinicalTrials.gov website by the principal sponsor/investigator prior to the enrollment of the first study subject.
The research study protocol specifies the method and timing of public release of all prespecified outcomes to be measured including release of outcomes if outcomes are negative or study is terminated early. The results must be made public within 24 months of the end of data collection. If a report is planned to be published in a peer reviewed journal, then that initial release may be an abstract that meets the requirements of the International Committee of Medical Journal Editors (http://www.icmje.org).
The research study protocol must explicitly discuss subpopulations affected by the treatment under investigation, particularly traditionally underrepresented groups in clinical studies, how the inclusion and exclusion criteria effect enrollment of these populations, and a plan for the retention and reporting of said populations on the trial. If the inclusion and exclusion criteria are expected to have a negative effect on the recruitment or retention of underrepresented populations, the protocol must discuss why these criteria are necessary.
The research study protocol explicitly discusses how the results are or are not expected to be generalizable to the Medicare population to infer whether Medicare patients may benefit from the intervention. Separate discussions in the protocol may be necessary for populations eligible for Medicare due to age, disability or Medicaid eligibility.
Consistent with section 1142 of the Social Security Act, the Agency for Healthcare Research and Quality (AHRQ) supports clinical research studies that CMS determines meet the above-listed standards and address the above-listed research questions.
C.*** Nationally Non-Covered Indications
Effective for services performed on or after January 09, 2014, CMS has determined that PILD for LSS is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.
D. ***Other
Endoscopically assisted laminotomy/laminectomy, which requires open and direct visualization, as well as other open lumbar decompression procedures for LSS are not within the scope of this NCD.

Claims Processing Instructions 
TN 2959 (Medicare Claims Processing)* 
_____________________________________________
Here is from WPS Medicare J5 LCD for Category III codes


Group*2*Paragraph:*For claims with dates of service on or after January 9, 2014, PILD, procedure code 0275T, is a covered service only when billed as part of a clinical trial approved by CMS per NCD-150.13. All Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis (PILD for LSS) claims: 
12/31/2014 and earlier should be processed with code 0275T. 
01/01/2015 and after use 2 different codes:
- G0276 for clinical trial with Identifier NCT02079038. Is a blinded randomized controlled clinical trial which includes a CMS-approved placebo procedure arm (See CR 8954);
- 0275T for all other clinical trials (See CR 8757).


Group*2*Codes:

0275T
PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR


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## dwaldman (May 16, 2017)

http://www.prnewswire.com/news-rele...or-medicare--medicaid-services-300419181.html

http://www.massdevice.com/vertos-medical-wins-cms-reimbursement-for-mild-procedure/

http://www.beckersspine.com/mis/ite...-approval-for-mild-procedure-5-key-notes.html



Vertos Medical did receive expanded coverage under clinical trial from CMS. I was not aware of this when I previously responded.


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## amandam2974 (Dec 18, 2017)

*Reimbursement for 62380*

We have physicians thinking about performing 62380.  This code does not have RVUs assigned at this time and is not on the Physician Fee Schedule but is contractor priced.  Does anybody have any experience with what the various MACs are reimbursing for this procedure for the physician fee?


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## dwaldman (Dec 20, 2017)

amandam2974,

WPS Medicare J5 has on their 2018 physician fee schedule an allowable amount for 62380 which is around $695 then they have additional amounts regarding past participation in PQRS and EHR incentive program.

https://www.wpsgha.com/wps/portal/m...E2_cxmwWdzge90L5Q/dz/d5/L2dBISEvZ0FBIS9nQSEh/


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