Spine Reimbursement Sees a Major Impact

2012’s bundling of procedures and assigning of “experimental” T codes can hamper provider reimbursement.

By Barbara Cataletto, MBA, CPC

Changes to CPT® 2012 spinal codes and coding guidelines have an important impact on reimbursement, new technologies, and the advancement of patient care. Let’s review the changes you’ll need to know to properly document and code these surgical cases.

Cardiovascular and Thoracic Surgery – CCVTC

63030 Not for Minimally Invasive Lumbar Decompressions

Compared to 2011, you’ll notice a discreet difference in the coding requirements for decompressions of the spine. Discectomy, hemilaminectomy, and interspace decompression now require greater detail about the surgical approach.

For example, 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar now describes an “open” procedure only (as does 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical). You may no longer report 63030 for minimally invasive (i.e., endoscopically assisted) lumbar procedures, as in previous years. Instead, 62287 and 0275T now cover percutaneous and endoscopic approaches:

  • 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar
  • 0275T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

Note that 62287 and 0275T bundle (include) many related procedures, such as fluoroscopy, imaging, discogram, etc. The bundled services may not be coded separately. The codes also describe procedures performed at either single or multiple levels; 0275T further describes either unilateral or bilateral procedures.

When selecting among 63030, 62287, and 0275T, you must review documentation language carefully to differentiate the approach and find the specific terminology necessary to support the chosen code. Look for terms such as “percutaneous,” “cannula,” “fluoroscopy,” “tubular,” “intralaminar,” “port incision,” and “endoscopic” to identify decompression by minimally invasive technique as described by 0275T and 62287. Further clarification is required to determine a needle-based approach (62287) versus a non-needle-based approach (0275T). The language here is very specific.

Minimally Invasive Fusion Now a Category III Procedure

Descriptors for 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) and 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) have been revised (removing “without”) for 2012 to require that fusion include a transverse technique. This is another critical change. To report a minimally invasive approach, the coder must now look to Category III codes:

0220T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic

0221T lumbar

+0222T each additional vertebral segment (List separately in addition to code for primary procedure)

As evidenced by the code descriptors, 0220T-0222T include fusion as well as instrumentation, grafting, etc. Prior to this year, these procedures have been coded separately in addition to 22610 and 22612; in 2012, the new codes cover everything.

Understand the T code Challenge

Category III CPT® codes, also called temporary codes or T codes, represent emerging medical technologies that have not yet been approved by the U.S. Food and Drug Administration (FDA). Unfortunately, payers often don’t acknowledge T codes as a viable code set, claiming that the procedures are experimental and not covered. To make matters worse, T codes are not assigned relative value units (RVUs). The lack of RVUs is significant because it signals to payers that a procedure or service is experimental, unconventional, and/or an unacceptable medical treatment. This could mean that effective procedures and services assigned T code status never “catch on,” due to a lack of reimbursement.

As an example, there are difficulties using T codes for pre-authorization, submission, and payment for services going back to the development and implementation of artificial spinal disc surgery. The artificial disc coding and reimbursement example amply illustrates how T code status has nearly destroyed the artificial disc procedure as an adjunct procedure to the spine surgeons’ repertoire.

In 2005, practices using unspecified procedure codes to report artificial disc procedures began using new Category III codes 0090T-0092T (total disc arthroplasty). Payers began treating these procedures as experimental. Years later, even now that CPT® directs coders to use 22856 (cervical) and 22857 (lumbar) to report artificial discs, many payers refuse to yield and pay for the procedures—for the most part due to past medical determinations.

In reviewing the 2012 CPT® changes, we see that several established spinal procedures have now been transferred to T codes. As mentioned, these include endoscopic discectomy (lumbar, 0275T; as well as 0274T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic) and facet fusion (thoracic and lumber, 0220T-0222T; as well as 0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical). Both endoscopic discectomy and facet fusion are widely accepted surgical procedures, with a significant history of success within the spine community. Surgeons performing these minimally invasive procedures (and facilities offering them) will likely feel a significant economic crunch with the shift from the traditional CPT® Category I code submission to T code submission.

Some payers understand the difficulties posed by T codes and have responded by providing coverage and reimbursement advisories on their websites, or may engage in “pre-surgical” discussions regarding coverage and reimbursement. Whenever there’s doubt, it’s best to be proactive and communicate directly with your payer representatives.

Proactive and cooperative communications will reduce post-surgical denials. Physicians will play a key role in educating and encouraging carriers to approve procedures if they can communicate effectively about the medical benefits to the patient.

Don’t Give Up Reimbursement without a Fight

Practices and facilities will be required in 2012 to reauthorize any previously authorized procedures that are now reported with a T code. Practices that do not confirm authorization may find themselves—as they have in the past with the artificial disc procedures—receiving denials for what are suddenly considered to be experimental or noncovered procedures.

Setting the standard for reimbursement if preauthorization is granted is a secondary challenge. Even with preauthorization and proven reimbursement history for endoscopic discectomy and minimally invasive facet fusion, the practice or facility will face challenges. T codes generally result in an immediate denial, regardless of approval status, and require in-depth appeals and audits on a regular basis. The ability to navigate these challenges requires continued communication via the appeals process. Practices will be forced to provide supportive documentation of the preauthorization, previous payment history for similar procedures, and a “stick to it” attitude toward an acceptable reimbursement solution.

One of the best defenses is a great offense. When dealing with T codes, pursue payer authorization in writing, inclusive of the CPT® codes and the patient’s diagnosis and name, specific to the individual case. This basic document is often considered unnecessary until the denial is received, and getting it up front will save a great deal of effort.

Fortunately, in the case of endoscopic discectomy and/or minimally invasive facet fusion, a practice or facility may look to historic payments from codes 63030, 22610, and 22612 to support the reimbursement levels they expect for the T codes that now apply. Review practice reporting to identify payment trends (both highs and lows) to develop an acceptable fee range for these procedures in your geographic area. This will be helpful in formulating and supporting reimbursement appeals.

Industry is not likely to embrace technologies if surgeons, unsure of reimbursement, are hesitant to perform new procedures. This may hurt patients the most. Developing technologies should involve open discussions about medical necessity, CPT® applications, and reimbursement issues during the research and development phase to reduce the possibility of undesirable or unacceptable coding and reimbursement results. Sharing in new developments requires commitments from industry, physicians, patients, and insurers if we are to continue the process of improved medical treatments and medical successes.

 

Barbara Cataletto, MBA, CPC, is CEO of Business Dynamics LLC and the founder and CEO of CaseCoder™.

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One Response to “Spine Reimbursement Sees a Major Impact”

  1. anthony Yeung says:

    You have provided a thorough review of the situation on procedures that are not only beneficial to patients, but I get better outcomes than traditional procedures in the patients that I operate on because of my experience.
    In Arizona, in 1997, the Industrial commission approved a special code for my transforaminal decompression procedure and a private payer agreed to a bundles carve out that includes the surgical facility fee. We also agreed to use the closest code that pays 25% more than the traditional code for an open procedure. I had to lobby for the code, supported by my state medical association and the state orthopedic society.

    No one else has done this. but the procedure in my hands have proven itself to be beneficial and cost effective, eliminating the need for fusion in about 80% of cases. Unfortunately, no matter what we do, the payers are only looking to pay less or not pay at all. Patients who realize this will rebel and and force insurance companies to change or find alternatives. surgeons who have established themselves will just have to build a reputation for a sought after procedure by their results, “guarantee” the results, and take cash only.

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