Orthopedic Coding Alert

Intradiscal Electrothermal Annuloplasty (IDET) is a minimally invasive, outpatient procedure used to treat lower back pain. Although approved by the FDA in 1998, IDET is still regarded by many carriers as experimental. While more carriers are reimbursing for IDET, their guidelines for claim submission vary significantly and, in some cases, run contrary to correct coding. Preauthorization and prospective negotiation of reimbursement are necessary for any carrier that will reimburse for IDET.

Alternative to Surgery

Chronic back pain can be caused by small disc herniations, internal disc tears or mild disc degeneration. IDET follows a diagnosis of 722.0-722.9 (intervertebral disc disorders), which is usually concluded via an MRI and diskography. IDET is usually the next step after a series of oral pain medications, therapeutic injections and/or physical therapy.
   
Under local anesthesia and with x-ray guidance, a catheter is inserted into the painful lumbar disc space. Heat is introduced via the catheter, which is advanced along the annulus of the disc. The heat of the catheter cauterizes the nerve endings and shrinks collagen fibers and tissue to strengthen the area. Proponents of IDET consider it a safer, less expensive alternative to more invasive spinal surgery, which carries greater risks for intra- and postoperative complications.

Many Code Combinations

There are several different code combinations to use when reporting the procedure. Because no CPT code exists to describe the procedure, most carriers require one of two unlisted-procedure codes, 22899 (unlisted procedure, spine) or 64999 (unlisted procedure, nervous system). While HCPCS has two recommended S codes for IDET, Medicare policy specifically states that these temporary codes are not payable. However, some private carries prefer the S codes to the CPT unlisted-procedure codes:
 

S2370 intradiscal electrothermal therapy, single interspace
 

S2371 each additional interspace (list separately in addition to code for primary procedure).

Despite the HCPCS Codes , some Medicare carriers require CPT Codes to report IDET. For example, Arkansas Blue Cross Blue Shield (BCBS), the Part B carrier for several southern states, requires that CPT 64999 be reported for IDET. HGSA (formerly Xact), the local Medicare Part B carrier for Pennsylvania, requires 22899.
 
Other coders report success with 62287 (aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar [e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy]) or 64622-64623 (destruction by neurolytic agent, paravertebral facet joint nerve ...). Some carriers will accept codes for fluoroscopy and catheterization in addition to the codes for the major procedure. Jessica Kibbe, CPC, coder/biller for Foundation Surgery Affiliates, an ambulatory surgical center in Houston, uses the following coding sequence:
 

62287
 

64622-64623 (lumbar levels)
 

76005 fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures, including neurolytic agent destruction

99070 supplies and materials.

"We have had a few denials of IDET as 'experimental,' but not that many," Kibbe says. "I always send an operative report with my claim. We appeal the experimental denials with past medical records and a cover letter explaining that the patient had no relief from previous treatment."
    
Kibbe also urges facilities to bill for the catheters using 99070 and submit an invoice from the supplier. This is appropriate when IDET procedures are done in the office. When they are performed in a hospital or surgicenter, the facility bills for supplies.
 
The code combination Kibbe uses is consistent with AAOS guidelines, articulated in the Complete Global Service Data Guide, which indicates that fluoroscopic guidance and drug supply are not bundled with 62287 and therefore are billable separately. While Kibbe notes little difference in payment amounts from carrier to carrier, she says that reimbursement has covered the practice's costs for the procedure.

Carriers Will Not Pay

Although both Arkansas BCBS and HGSA have policies for which code to use for IDET, neither agency will reimburse for it and both have written policies stating as much. According to HGSA's policy on IDET, "The medical literature does not clearly establish the clinical efficacy of this procedure. Therefore IDET and its associated services are considered not medically necessary and, as such, are ineligible for payment."
 
BCBS of California also has a published policy statement that it will not pay for this procedure. While Aetna US Healthcare does not have a policy specific to IDET, it considers thermal capsulorrhaphy of the shoulder (similar in nature to IDET) investigational and will not pay for it.
 
Kent Hendrix is manager of payer operations for Oratec, the company that manufactures the SpineCATH, now the only IDET procedure on the market.
 
The states where IDET is not a Medicare-reimbursable procedure include North Dakota, South Dakota, Alaska, Arizona, Hawaii, Nevada, Oregon, Washington, Colorado, Wyoming, Iowa, Pennsylvania, Arkansas, New Mexico, Oklahoma, Eastern Missouri and Louisiana.
  
"That may only represent three different agencies, but they have jurisdiction over several states," Hendrix says. He says Noridian, a carrier with jurisdiction over 10 western states, will not pay for IDET. He says that, generally speaking, when a Part B carrier has a written policy on IDET it will not reimburse for it. "When there is no policy, chances are better for payment," he says. When carriers like Arkansas BCBS and HGSA direct coders to the codes to report for IDET, this is strictly for reporting purposes and will not secure payment.
 
Oratec has a coding sequence for IDET that it recommends to practices, but only when the carrier does not accept unlisted-procedure codes or S codes. "The AMA recommendation is to use unlisted-procedure or S codes," Hendrix says. "But when those fail, we have heard of practices having success with other codes." For that reason, Oratec offers the following alternatives to 64999, 22899 and the S codes:
 

62287 aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar (e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy)
 

64640 destruction by neurolytic agent; other peripheral nerve or branch

72295 diskography, lumbar, radiological super-vision and interpretation.

Hendrix says these are coding suggestions based on feedback from coders and carriers as to what will work, not a policy that the company specifically recommends. Since a discography is usually done to diagnose and establish the need for IDET, reporting it again may be inappropriate. The codes suggested above should be considered only when unlisted-procedure or S codes are rejected by the carrier.

Preauthorization Pays Off

Coders stress the importance of preauthorization with any number of new or experimental procedures, and that is the case with IDET. Beth Fulton, CPC, coding specialist at Orthopaedic Specialists of the Carolinas in Winston Salem, N.C., says preauthorization is a must with IDET. "We send in the patient's medical records showing failed treatments and bill the unlisted-procedure code 64999. However, it's always a good idea to have direction from the carrier regarding which code (64999 or 22899) they prefer," Fulton says. She also submits a procedure report and a cover letter with information regarding IDET with the claim. "It's not necessary to report the unlisted-procedure code more than once, even when IDET is performed at more than one level." Fulton adds that coders should increase their fees for each additional level so the total amount billed could reflect several levels or interspaces, but only show one code and the number of units involved, i.e., 64999 x 2.
 
Preauthorization can also serve as critical protection from accusations of fraudulent coding, particularly when carriers require coders to report 62287, 64640, or anything other than an unlisted-procedure or S code. Since 62287 describes removal of disc material, and not its repair, as is the case with IDET, it is by a literal reading an incorrect code to report. But because unlisted-procedure and S codes have no RVUs attached to them, carriers may request an analogous CPT Code so they can better arrive at a reimbursement figure. In other words, they are requiring coders to report a code that comes closest to describing IDET, even though it may be incorrect. Yet physicians and coders who knowingly report incorrect codes open themselves up to allegations of fraud and abuse. But if the carrier requires those codes, the coder is left with few options other than to report them.
 
For these reasons, it is essential that the practice obtain in writing the carrier's guidelines for coding IDET. To do so, submit an operative report and ask the carrier to preauthorize both the procedure and the required codes. That pre-emptive step could stave off significant headaches in the event of an audit.
 
Hendrix says a CPT code for IDET has been requested from the AMA, although there is no word as to whether a code will be created. If so, it would not take effect until 2003 at the earliest. In the meantime, extra work on the front end is still the requirement for satisfactory outcomes to IDET claims.