Neurosurgery Coding Alert

CMS gets specific for health outcomes in PILD for LSS.

In mid-October 2013, CMS released its National Coverage Analysis for percutaneous image-guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS). Keep a watch on how this decision may affect your practice.

Understand the Condition You’re Treating

Spinal stenosis is the most common reason for lumbar spine surgery in adults over age 65. Lumbar spinal stenosis occurs when degeneration or some other condition causes the vertebral canal or intervertebral foraminal opening (nerve root exit site) to narrow. Spinal degeneration leads to bony changes (such as bone spurs) and thickening of the supporting ligaments. “While thickened ligaments are often described, the actual pathophysiological process likely represents ligament folding and redundancy from disc space narrowing,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

When choosing the appropriate diagnosis, base your coding on whether the patient exhibits neurogenic claudication:

• 724.02 (Spinal stenosis, lumbar region; without neurogenic claudication), or
• 724.03 (… with neurogenic claudication).

You might also have documentation to support reporting a potential underlying cause of spinal stenosis, such as spondylolisthesis (756.12, Spondylolisthesis congenital or 738.4, Acquired spondylolisthesis).

Symptoms: Patients usually present to the physician with symptoms such leg pain with neurogenic claudication (pain, numbness or weakness in the legs that worsens with standing or walking and is alleviated with sitting or leaning forward).

According to the CMS memo, “It appears consensus as to the definition of spinal stenosis has not been reached among experts. There is no ‘gold standard’ for diagnosis and treatment of stenosis because of variable signs and symptoms, physicians’ history-taking and physical methods and diagnostic tests.”

See How New Differs from Old

Treatment options for LSS have varied from conservative management on one end of the spectrum to invasive surgical decompression on the other. “The recent trend to minimally-invasive surgical approaches has led to the development of small open as well as percutaneous techniques to achieve similar extent of decompression,” says Przybylski. “However, the evidence to support efficacy of some newer treatment options is sometimes limited.”

The recent national coverage analysis focused on a newer technique for treating LSS that hasn’t responded to conservative therapies: percutaneous image-guided lumbar decompression, or PILD. The physician performs posterior decompression of the lumbar spine under indirect image guidance (X-ray, fluoroscopic, or CT) without any direct visualization of the surgical area. Experts consider PILD to be a relatively non-invasive procedure.

“The PILD/MILD procedure typically is a minimally invasive resection of the thickened ligamentum flavum,” explains Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. “This is the ligament that runs the length of the vertebral canal and connects the laminae between adjacent vertebrae. The thickening / inflammation of this ligament is one of the primary causes of spinal stenosis.”

Compare: The mild® procedure (minimally invasive lumbar decompression) is one type of a PILD procedure. mild® offers an alternative to a standard open laminotomy-laminectomy surgical decompression.

The mild® procedure currently is reported with code 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 [e.g., fluoroscopic, CT], with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar). As a Category III CPT® code (designated by the ‘T’ in the code), 0275T is a temporary code representing an emerging technology, service, or procedure.

Terminology difference: “Why Medicare used the term PILD rather than the MILD term is not clear, but my guess was that they wanted to include all potential percutaneous image guided lumbar decompression, not just the mild® procedure,” Hammer says. “They likely didn’t want to create a NCD (national coverage determination) specifically for MILD only to have another company come up with a similar technique with a different name as a potential loophole out of the national non-coverage policy.” “In general, CMS and AMA-CPT® will try to use broader terms for procedures rather than focusing on a single technology,” says Przybylski.

Note: If the surgeon performs laminotomy or hemilaminectomy using an open or endoscopically-assisted approach, you should file with the appropriate code from 63020-63035. For intervertebral percutaneous decompression using a needle-based technique, submit 62287 (Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection[s] at the treated level[s], when performed, single or multiple levels, lumbar).

Dig Through the CMS Decision Steps

The scope of this national coverage analysis (NCA) includes a review of the evidence on whether percutaneous image-guided lumbar decompression for LSS provides improved health outcomes in Medicare beneficiaries.

CMS released its proposed NCA related to PILD and opened a 30-day comment period in the spring of 2013. Some comments were outside the scope of the current NCA because they dealt with endoscopic or microsurgical procedures. CMS states that “procedures performed under direct visualization through an endoscope or microscope are not within the scope of this NCA.”

The question that CMS sought to answer was whether there was sufficient evidence to conclude that PILD improves health outcomes in Medicare beneficiaries with lumbar spinal stenosis. The CMS conclusion was that evidence did not support claims of clinical benefit because of several reasons:

• Lack of consensus on diagnostic criteria
• Lack of consensus on the treatment of LSS
• Uncertainty that the small amount of tissue removed with PILD is enough to make a structural difference for the patient.

Let Your Voice Be Heard

CMS proposes that PILD for LSS is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act, which means that PILD for LSS would be non-covered by Medicare.

If the non-coverage decision is implemented as a Medicare NCD, it would apply to all Medicare jurisdictions. Those Medicare jurisdictions that currently allow coverage for PILD procedures could no longer reimburse for the procedure.

The decision, however, has not been finalized.

To read the draft coverage determination, visit www.cms.gov and search for “Proposed Decision Memo for Percutaneous Image-guided Lumbar Decompression for Lumbar Spinal Stenosis (CAG-00433N).”