Neurosurgery Coding Alert

Coders await official stances from NASS and AAOS

If your neurosurgery practice is feeling the strain of the latest major NCCI bundle, you-re not alone--but surgeons aren't taking the news lying down.

In our May article -New Fusion Bundles Are Headed Your Way, Thanks to Version 12.1,- we reported that version 12.1 of the National Correct Coding Initiative 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]).

The NCCI bundle indicates that the procedures are mutually exclusive, and therefore, you should not report both a posterolateral fusion and interbody fusion.

Append Modifier 59 for Now

The North American Spine Society (NASS) is developing an official position, says Matthew J. Twetten, senior manager of Reimbursement and Health Policy at the NASS. In the meantime, spine surgeons tell Neurosurgery Coding Alert that they-ll continue to fight for their separate-procedure payment when they perform these procedures together.

After all, code 22630 (often reported for a posterior lumbar interbody fusion [PLIF] procedure) pays upwards of $1,500, which is a lot of money for surgeons to lose, especially since they can spend more than an hour performing the procedure.

Modifier method: Because the new bundle carries a -1- indicator, surgeons can append a modifier such as 59 (Distinct procedural service) to 22630 if the PLIF is a distinct procedural service. And one surgeon tells us that he intends to do just that when he performs a separately identifiable PLIF with a posterolateral fusion.

-I am vehemently against the new edit,- says Douglas Ehrler, MD, an orthopedic surgeon at the Crystal Clinic in Akron, Ohio. Until the NCCI rectifies the bundle, he intends to append modifier 59 to 22630 and submit a cover letter indicating exactly why he thinks the PLIF or transforaminal lumbar interbody fusion (TLIF) 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 is a standard posterior lateral fusion that has been around in various forms since the advent of spine surgery. It requires only exposing the facets and transverse processes in that area, and packing bone graft in that region.-

A PLIF (22630), on the other hand, is similar to a TLIF, Ehrler says. -The procedure essentially accomplishes a fusion of the anterior and middle columns of the spine (the interbody fusion between the vertebral bodies). The interbody fusion fuses where a disk space is, thus fusing the endplates of the two vertebrae together. This does not in any way fuse the posterior lateral region of the spine,- which is described by 22612.

Separate Spine Areas Should Lead to Separate Pay

Although surgeons may combine the procedures to combat extreme structural instability and/or for the oblation of a degenerative disk, 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. They should be payable as two separate procedures always, as one can be done without the other and vice versa.-

And 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 the bottom line for the insurance carrier is that 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.

Caution: Still, compliance experts don't advise using modifier 59 contrary to NCCI and CPT policy and principles (i.e., when the neurosurgeon performs 22612 and 22630 at the same level). Even with an explanatory letter, officials may see knowing misuse of the code or modifier as misrepresentation, and the penalties for impropriety outweigh the benefit of additional reimbursement.

The only way to resolve the issue may be through a legal challenge, but better that it be by advocating for proper payment than by defending against charges of fraud or abuse, some experts say. In any event, you should track such instances in case NCCI retroactively rescinds the bundle.

What you can do: While spine surgeons await the NASS- and AAOS- official positions on the edit, or any word from the NCCI that the edit might be reconsidered, you should think about contacting your local neuro-surgery and spine surgery associations to determine whether you can get involved in any regional efforts to try to repeal the edit.