Neurosurgery Coding Alert

Check the NCCI Policy Manual for clarity on lumbar fusions, laminectomies.

Preparing the spinal interspace for an arthrodesis procedure often requires the surgeon to perform a decompression laminectomy beforehand. While National Correct Coding Initiative (NCCI) edits do allow for an overriding modifier to be used with the laminectomy, you need to be acutely aware of when and when not include a laminectomy code with an arthrodesis.

Consider the following two scenarios:

Scenario 1: The physician performs an L4-L5 decompression laminectomy with bilateral facetectomies and foraminotomies followed by a posterior interbody arthrodesis on the same L4-L5 interspace.

Scenario 2: The physician performs a L4-L5 decompression laminectomy with bilateral facetectomies and foraminotomies followed by a posterior interbody arthrodesis at the L3-L4 interspace.

The following codes apply to the arthrodesis and laminectomy documented in both procedures, respectively:

• 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 and segment; lumbar
• 63047, Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar

In one of these two scenarios, you are allowed to bill out for both the arthrodesis and the laminectomy. Determining which one, however, requires you to go above and beyond your typical NCCI edit. You learned in the NCCI article on pages 49-50 that there is often more to consider than just NCCI eligibility when billing out for two anatomically related surgeries.

Here, you will have to implement what you have learned by utilizing the 2017 NCCI Policy Manual. According to chapters 4 and/or 8 of the 2017 NCCI Policy Manual:

• “CMS payment policy does not allow separate payment for CPT^® codes 63042 (laminotomy...; lumbar) or 63047 (laminectomy...; lumbar) with CPT^® codes 22630 or 22633 (arthrodesis; lumbar)  when performed at the same interspace. If the two procedures are performed at different interspaces, the two codes of an edit pair may be reported with modifier 59 appended to CPT^® code 63042 or 63047.”

In other words, under no circumstance does CMS allow you to bill 22633 with 63047 as long as they share the same interspace. Essentially, Medicare is saying that the work of a laminectomy overlaps enough with an » arthrodesis of the same interspace that the laminectomy is to be considered an inclusive part of the fusion.

With this, we can definitively conclude that Scenario 1 should only bill out using 22633 since the physician performs the laminectomy at the same interspace. Scenario 2, however, you can bill out with both 22633 and 63047 since the laminectomy occurs at a separate spinal interspace. You will apply modifier 59 (Distinct procedural service) or modifier XS (Separate structure) to 63047. In order to increase the likelihood of full reimbursement, consider sending these procedures as a paper claim with a written justification for the use of modifier 59 attached.

As the NCCI Policy Manual references, the same idea applies to procedure codes 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) and 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar). Any combination of 22630/22633 with 63042/63047 is not billable if the physician performs both procedures at the same interspace.

Keep current: Stay on top of any annual NCCI policy changes by downloading the NCCI Policy Manual from their webpage: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd.