Orthopedic Coding Alert

Angry about the new lumbar arthrodesis bundle? You-re not alone

The latest major NCCI bundle has started to affect orthopedic surgeon's wallets, but spine surgeons aren't taking the news lying down.
 
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) now bundles 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]).
 
The North American Spine Society (NASS) is now  developing an official position, says Matthew J. Twetten, senior manager of reimbursement and health Policy at  the NASS.
 
In the meantime, spine surgeons tell Orthopedic Coding Alert that they-ll continue to fight for their separate-procedure payment when they perform these procedures together. After all, code 22630 (often reported for a posterior lumbar interbody fusion [PLIF] procedure) pays upwards of $1,500, which is a lot of money for surgeons to lose, especially since they can spend over an hour performing the procedure.

Some Surgeons Look to 59

Modifier method: Because the new bundle carries a -1- indicator, surgeons can append a modifier such as 59 (Distinct procedural service) to 22630 if the PLIF is a distinct procedural service. And one surgeon tells us that he intends to do just that when he performs a separately identifiable PLIF with a posterolateral fusion.
 
-I am vehemently against the new edit,- says Douglas Ehrler, MD, an orthopedic surgeon at the Crystal Clinic in Akron, Ohio. Until the NCCI rectifies the bundle, he intends to append modifier 59 to 22630 and submit a cover letter indicating exactly why he thinks the PLIF or transforaminal lumbar interbody fusion (TLIF) is a separate procedure.
 
Here's the difference between the procedures: -A posterior lateral fusion [22612] involves laying bone graft in the posterior lateral gutters,- Ehrler says. -That is decortication of the transverse processes, facets, and packing bone in that area. This can be augmented with pedicle screws. This is a standard posterior lateral fusion that has been around in various forms since the advent of spine surgery. It requires only exposing the facets and transverse processes in that area, and packing bone graft in that region.-
 
A PLIF (22630), on the other hand, is similar to a TLIF, Ehrler says. -The procedure essentially accomplishes a fusion of the anterior and middle columns of the spine (the interbody fusion between the vertebral bodies). The interbody fusion fuses where a disk space is, thus fusing the endplates of the two vertebrae together. This does not in any way fuse the posterior lateral region of the spine,- which is described by 22612.

Separate Spine Areas Should Lead to Separate Pay

Although surgeons may combine the procedures to combat extreme structural instability and/or for the oblation of a degenerative disk, the surgeries occur in two separate areas of the spine. -They can be fused independently or in combination with each other,- Ehrler says. -Therefore, they are totally not mutually inclusive of one another. They should be payable as two separate procedures always, as one can be done without the other and vice versa.-
 
In addition, not only does the surgeon spend more time with the patient to add a PLIF to the fusion, but the patient is under greater risk. -You risk neurologic structures such as dura or nerve roots- during the PLIF, Ehrler says. And the bottom line for the insurance carrier is that it can actually be cheaper in the long run to perform a PLIF than to perform a spine surgery using an anterior approach on a patient.

What You Can Do

While spine surgeons await the NASS- and AAOS- official positions on the edit, or any word from the NCCI that the edit might be reconsidered, you should think about contacting your local orthopedic and spine surgery associations to determine whether you can get involved in any regional efforts to try to repeal the edit.