Orthopedic Coding Alert

CMS made a mistake, but clarification won’t happen right away.

If your practice performs lumbar arthrodesis, there’s some unfortunate news in the third quarter National Correct Coding Initiative (NCCI) edits.

The problem? The edits contain some inaccurate information concerning certain add-on codes for posterior lumbar interbody arthrodesis. This could lead to confusion and possible coding issues that can be rectified only after NCCI officially rescinds the edit. If you’re aware of the edit, your practice will be able to put procedures in place for dealing with any illegitimate denials.

Check out what this concerning NCCI edit is all about.

Edit Puts CMS, CPT^® on Opposite Sides

The 2023 third quarter NCCI edit that conflicts with the AMA/CPT reporting rules was effective July 1, 2023. The Centers for Medicare & Medicaid Services (CMS) created edits that made CPT^® add-on codes +63052 (Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure)) and +63053 (… each additional vertebral segment (List separately in addition to code for primary procedure)) column 2 component codes of their parent codes:

• 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar)
• +22632 (… each additional interspace (List separately in addition to code for primary procedure))
• 22633 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar)
• +22634 (… each additional interspace (List separately in addition to code for primary procedure))

This is concerning, as CPT^® codes +63052 and +63053 were developed as add-on codes to be reported when the work described is performed at the same interspace as the interbody arthrodesis (22630, +22632) or the posterolateral interbody arthrodesis (22633, +22634).

As a result of this erroneous code edit, practices will likely experience denials of CPT^® codes +63052 and +63053 when reported with codes 22630, +22632, 22633 and +22634 for dates of service July 1, 2023 through at least September 30, 2023 by Medicare and payers that follow Medicare guidelines. NCCI hasn’t put a firm date on when it will publish a correction to this edit, so keep an eye out for information on the exact date that NCCI rescinds the edit.

NCCI admits that this edit was published in error and will be rescinded as soon as possible, but likely not until the next quarterly publication of NCCI edits, and maybe later. When NCCI removes the edit, reimbursement will be retroactive to July 1, 2023, as this is the effective date of the edit.

Remember to Track Affected Claims

Your practice will need to track all cases where the following CPT^® code combinations are used:

• 22630 and +63052
• 22633 and +63052
• +22632 and +63053
• +22634 and +63053

What to do? Flag all claims using these code combinations for dates of service between July 1 and the eventual edit deletion date to identify inappropriate denials.

Also, be sure to monitor CMS communications for instructions on whether these claims must be resubmitted, or if they will be automatically reprocessed for payment.

Refrain From Using Modifier 59

Unfortunately, this is not a situation where it would be appropriate to override the code edit appending either modifier 59 (Distinct procedural service) or any of the X-EPSU modifiers to CPT codes +63052 or +63053, as this would indicate that the decompression procedures were performed at different levels than the arthrodesis.

For more information check out the edits yourself at https:// www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare/medicare-ncci-procedure-procedure-ptp-edits.

Co- written by Heidi Stout, BA, CPC, COSC, Coder on Call, Inc., Milltown, New Jersey