Neurosurgery Coding Alert

Question: We seek help in writing an appeal letter for nonpayment of two graft codes, 20936 and 20930 Spinal Bone Graft Appeals. These are rarely paid, but we are planning to write an appeal letter and then if we can't get payment after that process, then we plan to create an auto adjustment. We request help on how to do an appeal for something that has no RVU's and usually has a carrier administrative policy that does not support payment for these codes. Please suggest where to start and how to create a medical necessity.

Answer: It would be best for you to not waste your time appealing for the lack of payment for either +20936 (Autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinous process or laminar fragments] obtained from same incision [List separately in addition to code for primary procedure]) or +20930 (Allograft for spin surgery only; morselized, or placement of osteopromotive material [list separately in addition to code for primary procedure]), at least for Medicare payers.

Although CPT^® and the national Correct Coding Initiative (CCI) do not bundle spinal bone grafts with arthrodesis (22548-22812) and spinal instrumentation (22840-22855), Medicare designates graft procedures 20930 and 20936 as status "B" codes. CMS policy dictates that Medicare payers always bundle these codes into payment for other services. To reinforce this, the national Surgeon Fee Schedule Database assigns these codes zero relative value units. In this way, Medicare and third-party payers observing CMS guidelines effectively bundle spinal bone grafts 20936 and 20930 to any related procedure with which you would report them.

Medicare does not preclude you from reporting 20930 or 20936 with arthrodesis. Medicare, however will not pay you extra for the grafting procedures. And you cannot charge the patient for the disallowed amounts because Medicare has already paid you for these services as part of the payment for the primary procedure. Medicare payers, however, will reimburse the surgeon only for the arthrodesis and instrumentation.

Example: If your surgeon, during arthrodesis, uses a locally harvested autograft at C3-C4, you would report 20936 for the autograft, an appropriate arthrodesis code(s) to describe the fusion procedure, i.e. 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment) for cervical arthrodesis at the initial level and +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) for each additional level, and any instrumentation placed, using an appropriate code.

Remember: Private payers may reimburse 20930 and 20936. Do not stop reporting these procedures. Your best strategy with Medicare is simply to write off the codes as "disallowed."