2017 Coding and Reimbursement Concerns Directly Impacting ......procedures that are in current medical/surgical portfolios of physicians. •Changes are made to represent the current

2017 Coding and Reimbursement Concerns

Directly Impacting the Spine Industry

Presenter: Barbara Cataletto, MBA, CPC

2

Introduction

This presentation will guide you through the new 2017

coding changes for spine surgery.

These changes consist of new codes, revised codes and

deleted codes and will be reviewed with regard to their

applications and how this will affect your reimbursement.

The reimbursement discussion should be an exchange of

ideas and skills that have allowed us to manage to get

through the series of roadblocks to preauthorization or

reimbursement.

3

Clarification of Procedure Types

The primary approach and visualization define the service. Surgical services are presumed open, unless otherwise specified.

Percutaneous: Image-guided procedures performed with indirect visualization of the spine, without the use of any device that allows visualization through a surgical incision.

Endoscopic: Spinal procedures performed with continuous direct visualization of the spine through an endoscope.

Open: Spinal procedures performed with continuous direct visualization of the spine through a surgical opening.

Direct visualization: Light-based visualization; can be performed by eye, or with surgical loupes, microscope, or endoscope.

Indirect visualization: Image-guided, not light-based visualization.

4

New Codes 2017

• Usually the result of new procedures that have come into the medical/surgical arena and are of high demand.

• Represent a clearer distinction of the procedures performed so that the code descriptor more specifically supports the actual procedure.

• Not all new codes or new procedures with a Category I CPT codes will be covered by all carriers, so review the coverage policies for each specific carrier as it applies to new CPT codes and new technologies to avoid denials.

• May have to be evaluated to the way existing contractual agreements will be executed or updated to reflect the reimbursement.

5

2017 Coding Update: Code 62380 Added

LAMINOTOMY/DISCECTOMY

62380 Endoscopic decompression of spinal cord, nerve root(s),

including laminotomy, partial facetectomy,

foraminotomy, discectomy and/or excision of herniated

intervertebral disc, 1 interspace, lumbar

*Utilize the -50 Modifier for Bilateral Procedure.

6

Revised Codes 2017

Revised codes are still in effect, but the coding

descriptor contains changes that need to be

recognized.

This may impact the code set, the procedure performed,

or the application of that specific code to the case.

Be sure to read through the entire procedure descriptor

of the revised codes to ensure that the code you are

selecting still fits well in describing the procedure.

7

2017 Coding Update: Code 62287Revised as of 2017

PERCUTANEOUS DISCECTOMY

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

discography and/or epidural injection(s) at the treated

level(s), when performed, single or multiple levels, lumbar

*See new code 62380 to report endoscopic lumbar decompression.

8

2017 Coding Update: Code 0274TRevised as of 2017

LAMINOTOMY/DISCECTOMY

0274T Percutaneous laminotomy/laminectomy (interlaminar

approach) for decompression of neural elements, any

method, under indirect image guidance, single or

multiple levels, unilateral or bilateral; cervical or

thoracic

0275T Lumbar

9

Replaced Codes 2017

• Often replaced when the original code no longer represents the procedures that are in current medical/surgical portfolios of physicians.

• Changes are made to represent the current trends and to minimize coding difficulties.

• Replaced codes should not be used for cases as the codes are considered deleted as of 2017 and the new code sets should be utilized at the time they are considered active.

• There may be circumstances where the codes that have been deleted may still be utilized by certain carriers or carrier types, such as Workers Compensation or Private Carriers. Researching the outlying carriers is recommended.

• Replaced codes may have to be evaluated as to the way the existing contractual agreements will be executed or updated to reflect the coding changes.

10

Biomedical Devices

The CPT Editorial Panel approved deletion of this code at the October 2015 meeting after the code was identified by CMS in 2008 as a “fastest growing procedure” and again in 2011 as a “high expenditure procedural code that had not been reviewed in at least six years.”

22851 Application of intervertebral biomechanical device(s)

(e.g., synthetic cage(s), methylmethacrylate) to

vertebral defect of interspace (List separately in addition

to code for primary procedure)

*See new codes 22853, 22854 and 22859 to report insertion of

biomechanical devices beginning 01/01/17

11

A Closer Look at Biomechanical Device Coding

These three new codes are a result of CMS flagging CPT code 22851 on its list of high expenditure procedure codes not reviewed in at least 6 years.

The RUC recommended review of the code because of the frequency of use, historical consistent growth of utilization and the fact that the code had not been surveyed since April 1995.

The CPT Editorial Panel approved deletion of 22851 and creation of CPT codes 22853, 22854 and 22859 to report biomechanical device insertion at the October 2015 CPT meeting.

12

2017 Coding Update: Codes Replacing Code 22851

DELETED

22851 Application of Intervertebral Biomechanical Devices

NEW CODES

+22853 Insertion of interbody biomechanical device(s) with integral

anterior instrumentation for device anchoring, when

performed, to intervertebral disc space in conjunction with

interbody arthrodesis, each interspace

+22854 Insertion of intervertebral biomechanical device(s) with

integral anterior instrumentation for device anchoring, when

performed, to vertebral corpectomy(ies) (vertebral body

resection, partial or complete) defect, in conjunction with

interbody arthrodesis, each contiguous defect

+22859 Insertion of intervertebral biomechanical device(s) to

intervertebral disc space or vertebral body defect without

interbody arthrodesis, each contiguous defect

13


The difference in the codes:

• The location of the device placement; intervertebral disc space or the vertebral body defect with arthrodesis being performed:

• The location of the device placement; intervertebral disc space or the vertebral body defect without arthrodesis being performed:

22853 Interspace w Implant

22854 Vertebral Body Defect w Implant

22859 for Interspace or Vertebral Body Defect

14


Codes are reported per level and capture both the insertion of implant and the

integrated instrumentation, and further allows

for coding of the basic biomechanical implant

and the separate instrumentation, where

applicable, regardless of approach.

15


For cases in which the surgeon inserts an implant/device without integral instrumentation, that procedure should appropriately be reported as a separate anterior instrumentation in addition to the appropriate biomechanical device code and the primary procedure code:

• CPT Anterior Instrumentation Codes

• 22845

• 22846

• 22847

16

Anterior Cervical Discectomy with Fusion and Integrated System

• Anterior Cervical Single Level Diskectomy, Below C2

• Anterior Cervical Single Interbody Fusion

• Integrated Interbody System

22551 Arthrodesis, anterior interbody, including disc space

preparation, discectomy, osteophytectomy and

decompression of spinal cord and/or nerve roots;

cervical below C2

22853 Insertion of interbody biomechanical device(s) with

integral anterior instrumentation for device

anchoring, when performed, to intervertebral disc

space in conjunction with interbody arthrodesis,

each interspace

17

Anterior Cervical Discectomy with Fusion, Implant and Instrumentation

• Anterior Cervical Single Level Diskectomy, Below C2

• Anterior Cervical Single Interbody Fusion

• Anterior Cervical Instrumentation

• Biomechanical Implant

22551 Arthrodesis, anterior interbody, including disc space

preparation, discectomy, osteophytectomy and

decompression of spinal cord and/or nerve roots;

cervical below C2





each interspace

22845-59 Anterior instrumentation; 2 or 3 vertebral segments

18

Cervical Corpectomy with Fusion and Integrated System

• Anterior Cervical Corpectomy for Fracture

• Anterior Cervical Spine Single Level Interbody Fusion


• Morselized Allograft

63081 Vertebral corpectomy (Vertebral body resection), partial or complete, anterior approach with decompression of spinal cord

and/or nerve root(s); cervical, single segment

22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare the interspace (other than for decompression); cervical below C2Insertion of interbody biomechanical device(s) with integral anterior instrumentation for device anchoring, when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace

22854 Insertion of intervertebral biomechanical device(s) with integral anterior instrumentation for device anchoring, when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect

20930 Allograft, morselized or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure.)

19

Cervical Corpectomy with Fusion and Instrumentation

• Anterior Cervical Corpectomy for Fracture

• Anterior Cervical Spine Single Level Interbody Fusion


• Anterior Plate


63081 Vertebral corpectomy (Vertebral body resection), partial or complete,

anterior approach with decompression of spinal cord and/or nerve

root(s); cervical, single segment

22554 Arthrodesis, anterior interbody technique, including minimal discectomy

to prepare the interspace (other than for decompression); cervical below

C2Insertion of interbody biomechanical device(s) with integral anterior

instrumentation for device anchoring, when performed, to intervertebral

disc space in conjunction with interbody arthrodesis, each interspace

22854 Insertion of intervertebral biomechanical device(s) with integral anterior

instrumentation for device anchoring, when performed, to vertebral

corpectomy(ies) (vertebral body resection, partial or complete) defect, in

conjunction with interbody arthrodesis, each contiguous defect



20

Lumbar Interbody Fusionand Integrated System

• Anterior Lumbar Single Level Interbody Fusion



22558 Arthrodesis, anterior interbody technique, including

minimal diskectomy to prepare interspace (other

that decompression); lumbar





each interspace

20930 Allograft, morselized or placement of osteopromotive

material, for spine surgery only (List separately in

addition to code for primary procedure.)

21

Lumbar Interbody Fusionand Implant and Instrumentation

• Anterior Lumbar Single Level Interbody Fusion


• Anterior Instrumentation









each interspace


20930 Allograft, morselized or placement of osteopromotive

material, for spine surgery only (List separately in


22

Lumbar Anterior Interbody Fusionand Integrated System

• Anterior Lumbar Fusion, 2 Levels

• Integrated Interbody System; 2 interspaces

• Allograft; morselized

22558 Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other that

decompression); lumbar

22585 Arthrodesis, anterior interbody technique, each additional interspace, lumbar (List separately in addition to code for primary procedure.)

22853x2 Insertion of interbody biomechanical device(s) with integral anterior instrumentation for device anchoring, when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace


23

Lumbar Anterior Interbody Fusionand Instrumentation

• Anterior Lumbar Fusion, 2 Levels

• Biomechanical Implant; 2 interspaces

• Anterior Instrumentation

• Allograft; morselized




22585 Arthrodesis, anterior interbody technique, each

additional interspace, lumbar (List separately in


22853x2

22845-59

Biomechanical Mechanical Implants with Separate

Anterior instrumentation; 2 or 3 vertebral segments

20930 Allograft, morselized or placement of

osteopromotive material, for spine surgery only (List

separately in addition to code for primary

procedure.)

24

Lumbar Posterior Interbody Fusionand Instrumentation

• Posterior Lateral Lumbar Fusion, Single Level

• Posterior Lumbar Single Level Interbody Fusion


• Posterior Lumbar Non-segmental Instrumentation

• Iliac Crest Bone Graft; morselized

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

22853 Insertion of interbody biomechanical device(s) with integral

anterior instrumentation for device anchoring, when

performed, to intervertebral disc space in conjunction with

interbody arthrodesis, each interspace

22840 Posterior non-segmental instrumentation (e.g., Harrington

Rod technique, pedicle fixation across one interspace)

20937 Autograft for spine surgery only (includes harvesting the

graft); morselized (through separate skin of fascial incision)

25

2017 Coding Update: Codes Replacing Codes 0171T & 0172T

0171T Insertion of posterior spinous process distraction device

(including necessary removal of bone or ligament for

insertion and imaging guidance), lumbar; single level

0172T Each additional level

22867 Insertion of interlaminar/interspinous process

stabilization or distraction device, without fusion,

including image guidance when performed, with open

decompression, lumbar; single level

+22868 Second level

22869 Insertion of interlaminar/interspinous process

stabilization or distraction device, without open

decompression or fusion, including image guidance

when performed, lumbar; single level

+22870 Second level

Codes Replacing Codes 0171T & 0172T

26

2017 Coding Update: Codes Replacing Codes 62310 & 62311

62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contract for localization when performed, epidural or subarachnoid; cervical or thoracic

62311 Lumbar or sacral (caudal)

62320 Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution, not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

62321 With imaging guidance (i.e., fluoroscopy or CT)

62322 Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution, not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance


Codes Replacing Codes 62310 & 62311

27

2017 Coding Update: Codes Replacing Codes 62318 & 62319

62318 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s)(including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

62319 Lumbar or sacral (caudal)

62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s)(including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic, without imaging guidance


62326 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s)(including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal), without imaging guidance


Codes Replacing Codes 62310 & 62311

28

Revised Codes 2017

Revised codes are still in effect, but the coding descriptor contains changes that need to be recognized. This may impact the code set, the procedure performed, or the application of that specific code to the case.

Be sure to read through the entire

procedure descriptor of the revised codes

to ensure that the code you are selecting

still fits well in describing the procedure.

29

2017 Coding Update: Code 0200T & 0201T Revised

SACROPLASTY

0200T Percutaneous sacral augmentation, unilateral

injection(s), including the use of a balloon or

mechanical device, when used, 1 or more needles,

including imaging guidance and bone biopsy, when

performed

0201T Percutaneous sacral augmentation, bilateral

injection(s), including the use of a balloon or

mechanical device, when used, 2 or more needles,

including imaging guidance and bone biopsy, when

performed

30

Deleted Codes 2017

Deleted codes can no longer be used for the years following the time they became inactive.

It is necessary to look to new or updated codes

or refer to the unspecified codes if necessary.

Some procedures have been absorbed into the

E&M code sets and are no longer billable

separately.

31

2017 Coding Update: Deleted Codes 22305, 0284T & 0285T, 0282T & 0283T

DELETED CODES

22305 Closed treatment of vertebral process fracture(s)

0284T Revision or removal of pulse generator or electrodes,

including imaging guidance, when performed,

including addition of new electrodes, when performed

0285T Electronic analysis of implanted peripheral

subcutaneous field stimulation pulse generator, with

reprogramming when performed

0282T Percutaneous or open implantation of neurostimulator

electrode array(s), subcutaneous, cervical, thoracic or

lumbar, for trial, including removal at the conclusion of

the trial period

0283T Permanent, implantation of neurostimulator with

implantation of a pulse generator

32

Show me the money

33

Physician Reimbursement Formula

ISASS participated in the CPT and RUC

processes for several of these new codes and

is disappointed that despite our best efforts,

CMS did not follow the RUC recommendations

for several of the new codes, and instead

assigned lower final values.

34

Reimbursement Formula

CODE DESCRIPTOR WORK RVU

PRACTICE EXPENSE RVU

MALPRACTICERVU

TOTAL RVU

2017 REIMBURSEMENT

22853 Insertion of interbody biomechanical

device(s) (e.g., synthetic cage, mesh) with


anchoring (e.g., screws, flanges) when

performed to intervertebral disc space in

conjunction with interbody arthrodesis,

each interspace

4.25 2.03 1.36 7.64 $274.19

22854 Insertion of intervertebral biomechanical

device(s) (e.g., synthetic cage, mesh) with


anchoring (e.g., screws, flanges) when

performed to vertebral corpectomy(ies)

(vertebral body resection, partial or

complete) defect, in conjunction with

interbody arthrodesis, each contiguous

defect

5.50 2.63 1.76 9.89 $354.94

22859 Insertion of intervertebral biomechanical

device(s) (e.g., synthetic cage, mesh,

methylmethacrylate) to intervertebral disc

space or vertebral body defect without

interbody arthrodesis, each contiguous

defect

5.50 2.63 1.76 9.89 $354.94

35

New Code: 2017 Fess

These are the fees for NYC 2017

In 2016, CPT 22851 was $515.02

Significant decrease in the fee Code Payment

22853 $328.48

22854 $435.21

22859 $425.21

36

Code 22845 Payment Rates

Payment rates code 22845

in the NYC area:

Year 2016 Year 2017

$919.85 $929.16

37

Code 62380 vs 63030 RVUs

• Code 63030: 35.89 RVUs

• Code 62380 Contractor Pricing

• Noted to be approximately 10.50 RVUs

38

Facility Reimbursement

39

OPPS SPINE PROCEDURE CATEGORIES

5111 Level 1 Musculoskeletal Procedures 2.6633 $199.75

5112 Level 2 Musculoskeletal Procedures 16.2251 $1,216.90





40

OPPS Spine Fusion

22551 Neck spine fuse & remov bel c2 $9557.20

22554 Neck spine fusion $9,557.20

22612 Lumbar spine fusion $9,557.20

22552 Addl neck spine fusion

22585 Additional spinal fusion

22614 Spine fusion extra segment

22840 Insert spine fixation device



22853 Insj biomechanical device


22858 Second level cer diskectomy


41

New Code for ASC Reimbursement

22867 Insj stablj dev w/dcmprn $10,541.98

22869 Insj stablj dev w/o dcmprn $10,541.98

62380 Ndsc dcmprn 1 ntrspc lumbar $3,631.80




22868 Insj stablj dev w/dcmprn

22870 Insj stablj dev w/o dcmprn

42

ASC Cervical Spine

22551 Neck spine fuse&remov bel c2 156.54 $7,046.62

22554 Neck spine fusion 154.91 $6,973.22


22585 Additional spinal fusion







22858 Second level cer diskectomy


43

ASC Lumbar Fusion

22612 Lumbar spine fusion $4,974.12


22840 spine fixation device



44

ASC: Ambulatory Surgery Center

Anterior Cervical Discectomy w Fusion and Implant $7,046.62

22551 Neck spine fuse & remov bel C2



22853 Inj biomechanical device

45

OPPS Decompression

63045 Remove spine lamina 1 crvl 5114 $5,219.36

63047 Remove spine lamina 1 lmbr 5114 $5,219.36

63056 Decompress spinal cord lmbr 5114 $5,219.36

46

Reimbursement Perspectives

47


• Carrier Formulary vs Surgeon Preference

• Med Review; Third Party Interpretation Woes

• Peer to Peer Requirements

48


• Denials and Appeals

• Processes and Changes

• Number of Appeal Opportunities

• Reprocess, Reconsideration or Appeal

49


• Carrier Policy Decisions

• Denials for Decompression with Interbody Fusion

• Denials for Corpectomy Based on Diagnosis

50

Closing Comments

You should now have a better understanding of

the coding changes and their new applications

as well as a greater knowledge of how these

changes will effect your reimbursement for 2017.

Our Reimbursement Discussions should help

lighten the load now that you have options to

move through the Maze of Obstacles placed

before you.

are BOLDER.

TITLE: INS AND OUTS OF SPINE SURGERY

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52

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Documents

2017 Coding and Reimbursement Concerns Directly Impacting ......procedures that are in current medical/surgical portfolios of physicians. •Changes are made to represent the current