Neurosurgery Coding Alert

Question: We have received a denial for payment for CPT® code 20931 (Allograft, structural, for spine surgery only [List separately in addition to code for primary procedure]) as it is packaged into 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) and/or 22845 (Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to code for primary procedure]). Please help us to understand the reason for this denial.

North Carolina Subscriber

Answer: In addendum B for the outpatient hospital fee schedule, Medicare lists 20931 as having a 'N' status indicator as packaged service; no separate payment made. They recently took 22551 off of the inpatient only list, but if a plate/instrumentation 22845 is placed in addition to 22551 and 20931 it would only be reimbursed for the facility on inpatient basis since 22845 has a status indicator of 'C' Inpatient procedure. For the an inpatient claim, the fusion ICD-9 volume 3 procedure code would include instrumentation and allograft, so if they have similar reimbursement methodologies as Medicare, they are right in not reimbursing 20931 on the facility side as a separate payment for hospitals. Read more on https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html