Medicare Compliance & Reimbursement

Spine surgeons stiffen their backbones in opposition to bundle.

Watch out: A new Correct Coding Initiative edit could make life more difficult if your surgeon performs two common spine procedures together.

The edit: CCI Version 12.1 bundles 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar) into 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]).

Code 22630 (often reported for a posterior lumbar interbody fusion (PLIF)) pays upwards of $1,500.

Surgeons Stand Up In Opposition

“I am vehemently against the new edit,” says Douglas Ehrler, MD, an orthopedic surgeon at the Crystal Clinic in Akron, OH. The edit can be overridden with a modifier, so he intends to append modifier 59 to 22630 and submit a cover letter indicating exactly why he feels the PLIF is a separate procedure.

Here’s the difference between the procedures: “A posterior lateral fusion [22612] involves laying bone graft in the posterior lateral gutters,” Ehrler says. “That is decortication of the transverse processes, facets, and packing bone in that area. This can be augmented with pedicle screws.” This only involves exposing the facets and transverse processes in that region, and then packing bone graft.

A PLIF (22630), on the other hand, fuses the anterior and middle columns of the spine, Ehrler explains. “The interbody fusion fuses where a disc space is, thus fusing the endplates of the two vertebrae together.” This doesn’t fuse the posterior lateral region of the spine, which 22612 covers.

“Adding the 22612 poster lateral fusion to the 22630 fusion increases the likelihood of fusion and therefore the chance of pain relief,” says James Hollowell, a neurosurgeon in Milwaukee, WI who specializes in spine surgeries. It’s true that studies conflict on the merits of performing both procedures, and there’s no convincing body of evidence either way, he notes. But 22630 “clearly requires additional work and should be compensated accordingly,” the neurosurgeon says.

Separate Spine Areas Should Lead To Separate Pay

Surgeons may combine both procedures to combat extreme structural instability and/or for the oblation of a degenerative disc. But the surgeries occur in two separate areas of the spine. “They can be fused independently or in combination with each other,” Ehrler says. “Therefore, they are totally not mutually inclusive of one another.”

Not only does the surgeon spend more time with the patient to add a PLIF to the fusion, but the patient is under greater risk. “You risk neurologic structures such as dura or nerve roots” during the PLIF, Ehrler says. And it can actually be cheaper in the long run to perform a PLIF than to perform a spine surgery using an anterior approach on a patient.

The bottom line: Medicare shouldn’t try to legislate the surgeon’s choice of procedures “by placing a chokehold on the reimbursement,” says the Milwaukee surgeon.

What you can do: Contact your local and national orthopedic and spine surgery associations to determine whether you can get involved in any efforts to try and repeal this edit.

Another alternative: You can still bill for the application of cages or other devices intervertebrally using CPT code 22851, says Katherine Phelan, coder with St. John’s Health System in Tulsa, OK. And you can bill separately for the laminectomy using 63047. So she would bill the following codes for a lumbar laminectomy with posterior and interbody fusion:

· 22630 (plus additional levels)
· 63047 (plus additional levels)
· 22840-22842 (depending on levels)
· 22851 for each interspace where a device was inserted using graft codes 20900-20999.