Neurosurgery Coding Alert

You needn't worry about NCCI Edits with most bone graft/spinal fusion combinations

Although CPT and the National Correct Coding Initiative (NCCI) bundle bone grafting into some surgical procedures, you can safely report 20930-20938 with most spinal arthrodesis and instrumentation codes, which can yield you as much as $200 more per claim.

Don't Let Payer Misunderstanding Affect Your Payment

When coding for spinal fusions (22548-22812) and/or instrumentation placement (22840-22855) with bone grafts (20930-20938), you should separately report (and expect separate payment for) the grafting procedures, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. (See page 35 for a full description of spinal fusion, instrumentation and bone graft codes.)
 
Although CPT and NCCI bundle bone grafts to many orthopedic procedures (for example, 23480, Osteotomy, clavicle, with or without internal fixation ), these bundles do not apply to arthrodesis (22548-22812) and spinal instrumentation (22840-22855) procedures.

Take action on bundled claims: Because many payers are familiar with bundling bone graft codes, you may notice that they deny separate payment for 20930-20938 when reported with arthrodesis or spinal instrumentation. If this happens to you, be sure to appeal the claim, noting that CPT specifically instructs, "Codes for obtaining autogenous bone ... grafts ... should be reported separately unless the code descriptor  references the harvesting of the graft or implant." Not only do the arthrodesis codes not reference the harvesting of bone grafts, a parenthetical reference preceding the arthrodesis codes states, "To report bone graft procedures, see codes 20930-20938."

Beware of these exceptions: If you report 20930 or 20936, however, don't expect to collect -- at least from Medicare payers. Medicare assigns no relative value units (RVUs) to 20930 or 20936 and considers them to be bundled services, according to the 2004 Physician Fee Schedule database. Therefore, Medicare payers will always bundle these codes into the more extensive procedure (for instance, the arthrodesis reported at the same time).

Leave -51 Off Spinal Bone Graft Codes

CPT defines bone grafts as exempt from multiple- procedure rules, so you should not append modifier -51 (Multiple procedures) to 20930-20938. Accordingly, the February 1996 CPT Assistant states, "Codes 20930-20938, although appearing under the heading of General Musculoskeletal Procedures, apply only to bone grafts used for spine surgery ... These are specifically identified as add-on procedures. The -51 modifier is not used when these codes are reported with the definitive spine surgery code."

Because modifier -51 does not apply to these grafting codes, your payer should not cut your fee when you report 20931, 20937 or 20938 with an arthrodesis code, Sandham says. Once again, if the payer cuts your payment, appeal the claim and cite CPT guidelines to support your position.

Choose Autografts When Harvesting From Patient

Surgeons obtain bone grafts from either an allograft or an autograft, and the codes differ depending on the graft type.

If the surgeon obtains the graft from the patient's own body (for example, he takes bone from the patient's rib to complete a spinal fusion), you should report an autograft code (20936-20938). Select 20936 if he obtains the graft from a bone he accesses through the same incision as the fusion, says Annette Grady, CPC, CPC-H, senior healthcare consultant at Eide Bailly LLP in Bismarck, N.D., and chair of the North American Spine Society's administrative task force. Choose 20937 or 20938 if the surgeon must create a separate skin or fascial incision at a different site to harvest the graft.

Surgeons do not personally harvest allografts, which explains why reimbursement is normally $60-80 less for allograft codes than autograft. Allografts come from cadavers or living donors, and the codes describe the surgeon's work preparing and placing the allograft.

CPT further breaks down grafting codes as morselized or structural. Structural bone grafts (20931 and 20938) consist of single pieces of bone that provide direct support for skeletal structures. Morselized grafts (20930 and 20937) consist of small bone fragments joined together to fill bony cavities, primarily to promote new bone growth.

Don't Stop at One Grafting Code

Surgeons who perform complicated arthrodesis procedures at multiple levels might use more than one graft type, and in some situations you can collect reimbursement for each grafting procedure.

The rules: If the surgeon uses the same type of graft multiple times, some payers will not reimburse you for additional levels. "Each type of bone graft code for spinal surgery (20930-20938) may be reported one time for a spinal procedure, regardless of the number of vertebral levels being surgically fused (i.e., not once per spinal interspace or segment fused)," according to the January 2004 CPT Assistant.

The phrase "Each type of bone graft" leaves some coders wondering how to report a session during which the surgeon uses both autograft and allograft.

The solution: Although CPT once advised coders to report only one graft code per session, CPT eliminated this instruction in 2001, Grady says. In addition, the NCCI does not bundle the grafting codes into one another, and some coders have reported success billing more than one grafting code when the surgeon places grafts at multiple levels. "When billing in this manner, be sure to include an operative report clearly illustrating that the surgeon addressed two separate interspaces (e.g., C5/C6 and C6/C7)," Grady says.

Some payers may not reimburse more than one grafting code per operative session, but this does not apply to every insurer. Therefore, unless the payer specifies otherwise, you should report each separate type of graft that your surgeon performs.

"The 2003 North American Spine Society (NASS) publication Common Coding Scenarios for Comprehensive Spine Care advises coders to list more than one bone graft code for spine procedures if it was done," says Denise Paige, CPC, coding manager at Beach Orthopedic Associates in Long Beach, Calif., and president of the American Academy of Professional Coders' Long Beach Chapter. "Whether or not you will be paid for more than one bone graft is another issue, but for reporting purposes you would be wise to list each type of bone graft used."