Neurosurgery Coding Alert

Question: Our local Medicare carrier consistently refuses to pay for local autografts (20936) during spine surgery. My understanding is that all spinal bone graft codes are "modifier 51 exempt" and separately reportable with, for instance, arthrodesis and instrumentation. Should I appeal these claims?

New Jersey Subscriber

Answer: You shouldn't waste your time appealing 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 [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 Physician 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.

In other words: Medicare does not preclude you from reporting 20930 or 20936 with arthrodesis, for instance, but it 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.

So, for example, if during arthrodesis the surgeon 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 (for example, 22600, Cervical arthrodesis at the initial level; and +22614 for each additional level) and any instrumentation placed, using an appropriate code.

Medicare payers, however, will reimburse the surgeon only for the arthrodesis and instrumentation.

A point to remember: Private payers may reimburse 20930 and 20936, so you should not stop reporting these procedures. Your best strategy with Medicare is simply to write off the codes as "disallowed."