Orthopedic Coding Alert

NCCI retroactively deletes PLIF/Interbody fusion bundle--and so should you

Spine surgeons who were dismayed by the NCCI's April edit that bundled 22630 into 22612 finally have something to cheer about. The NCCI has not only reversed the edit but has made the deletion retroactive, so you can collect any money you-ve lost since April due to the edit.

In our May article -Don't Expect Payment for Interbody Fusion With Posterolateral Fusion,- we reported that version 12.1 of the National Correct Coding Initiative (NCCI) bundled 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar) into 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) effective April 1.
 
Spine surgeons and their associations vehemently argued against the edit, saying that the two procedures were not mutually inclusive of one another and that they would continue to fight the edit. The NCCI recently released a statement confirming that the edit will be deleted with version 12.3 of the new edits, which will be released on Oct. 1, 2006.

Compile Your Denied Claims and Prepare to Resubmit

-The North American Spine Society (NASS) and the AANS/CNS sent a letter to the NCCI last month documenting reasons why the edits were incorrect, and NCCI and CMS agreed with our analysis and agreed to reverse the edits, effective Oct. 1 and retroactive to April 1,- says Matthew J. Twetten, senior manager of reimbursement and health policy at the NASS.

Get your denials ready for the Oct. resubmission date: Because the edit deletion will be retroactive to April 1, you can resubmit your claims after Oct. 1 if your carrier denied any claims based on the edit. Include a letter explaining why you-re resubmitting the claim seeking reimbursement for the interbody fusion.

Coders are already reviewing claims to check for previous denials that they-ll need to appeal. Changes to NCCI edits -always cause me to dig deeper and check for accuracy and documentation to substantiate anything we are billing,- says Katherine Phelan, coder for St. John's Health System in Tulsa, Okla.

Remember: If your surgeon performed both procedures together and you only billed the PLIF (22612) because you knew the payer would deny 22630, you can still resubmit your claim, even though you don't have a denial letter. You should send the payer a copy of the surgeon's op report, along with a letter stating that you collected for the PLIF but that you-re now requesting payment for the interbody fusion, which you originally didn't bill due to the previous edit.

Looking ahead: Once the NCCI formalizes the edit deletion on Oct. 1, you will not need to append any modifiers to your claim if you bill 22630 and 22612 together, unless your payer requires you to attach modifier 51 (Multiple procedures) to subsequent line items. If that is the case, you will report 22612 followed by 22630-51, because 22612 is the higher-paying service.