Resources

Medicare Fee Calculator

Using AMA's 2012 CPT^® codes and CMS' 2013 Physician Fee Schedule, the Healthcare Economic Services (HES) department has developed this tool to assist you in calculating Medicare fees for physicians in the private sector. Because the rates vary by geography, the fee calculator can be used to determine the varying levels of reimbursement when a physician is considering relocation. Many other factors are involved in practice location, organizational affiliation, and provider panel participation. However, the fee calculator can provide useful comparisons when physicians need to know prevailing rates within a region.

Medicare provides care for a great number of people and as such is the primary purchaser of health care services. The rates for Medicare are set annually and commercial payer organizations review these published rates when determining what level of reimbursement they will pay providers. Depending upon the degree of managed care penetration, physicians often see payer rates set at some percentage higher than the Medicare rates. Therefore, it can be very beneficial for physicians to review the most current reimbursement levels for each CPT listing when determining the fee schedule to be used in their practices or when evaluating managed care contract proposals.

To use the calculator, select the geographic area you wish to review. You can enter as many as ten CPT codes. For comparative purposes, you may also elect to input your fee schedule. The CPT codes available in this calculator include those codes most frequently used for the care of spine patients to include evaluation and management, spine, cranial, injection procedures, and diagnostic procedures. The Medicare allowance will calculate based on the 2013 published RVUs and a conversion factor of $34.0376.

For additional information or assistance, feel free to email the SpineLine.

There may be slight variations due to rounding.

Open Calculator

This fee calculator is intended as a comparative resource only. The calculations are based upon CMS data published in the Federal Register for 2012 and will be updated each January as new CMS data is available. Any other use of this information is not authorized by Medtronic. Current Procedural Terminology (CPT^®) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

About Infuse Bone Graft (rhBMP-2)

Infuse^® Bone Graft consists of two parts: a solution containing rhBMP-2 (recombinant human bone morphogenetic protein 2) and the ACS (absorbable collagen sponge). The protein is a genetically engineered version of a natural protein normally found in small quantities in the body. The purpose of the protein is to stimulate bone formation.

More than 40 years ago, orthopaedic surgeons determined that the protein extracts required for bone to heal, or regenerate, in the body were contained within the bone itself. In 1979, Dr. Marshall Urist, a professor in the Department of Orthopaedic Surgery at the University of California at Los Angeles School of Medicine, coined the term "bone morphogenetic protein" (BMP) to describe these proteins.

Approximately 20 BMPs with different amino acid structures have been isolated to date, but only six appear capable of initiating bone growth. Of these, rhBMP-2 has demonstrated the potential to form bone.

Medtronic Procedures

The PDFs below contain illustrations and explanations of commonly performed spinal procedures.

Cervical

Anterior Cervical Discectomy and Fusion (PDF, 732 KB)

Anterior Cervical Corpectomy (PDF, 482 KB)

Posterior Cervical Decompression and Fusion (PDF, 723 KB)

Lumbar

Lumbar Laminectomy and Discectomy (PDF, 877 KB)

Anterior Lumbar Interbody Fusion (ALIF) (PDF, 1.0 MB)

Posterior Lumbar Interbody Fusion (PLIF) (PDF, 1.3 MB)

Transforaminal Interbody Fusion (TLIF) (PDF, 862 KB)

Spinal Anatomy

Anatomy

The spine is a very complex mechanical structure that is highly flexible yet very strong and stable. In the normal spine, regardless of your position or activity, including sleeping, there is always some type of physical demand being placed on it.

The primary functions of the spine include:

• Protecting the spinal cord, nerve roots, and internal organs
• Providing flexibility of motion
• Providing structural support and balance for upright posture. The spine bears the load of the head, shoulders and arms, and upper body. The upper body weight is then distributed to the hips and legs. The spine attempts to keep the body’s weight balanced evenly over the pelvis. This reduces the amount of work required by the spinal muscles and can eliminate muscle fatigue and back pain.

The normal adult spine is balanced over the pelvis, requiring minimal workload on the muscles to maintain an upright posture. Loss of spinal balance can result in strain to the spinal muscles and deformity of the spine as it attempts to maintain an upright posture.

 

Detail

Regions of the Spine

There are 33 vertebrae in the spine. The illustration is a lateral (side) view of a normal spine and it shows the locations of the five major spinal levels.

• The cervical region has seven vertebrae (C1 through C7).
• The thoracic region has 12 vertebrae (T1 through T12).
• The lumbar region has five vertebrae (L1 through L5).
• The sacral region consists of five vertebrae all fused together to form one continuous bone mass known as the sacrum.
• The coccygeal region consists of four vertebrae, all fused together to form the coccyx or tailbone.

Vertebrae

Although the vertebrae have slightly different appearances as they range from the cervical spine to the lumbar spine, they all have the same basic structures, and the structures have the same names. Only the first and second cervical vertebrae are structurally different in order to support the skull.

Each vertebra has an anterior arch and a posterior arch, which form a hole called a foramen. The spinal cord passes through the foramen of each vertebra.

The anterior arch is called the vertebral body. Discs connect one vertebral body to another to allow motion of the spine and cushion it against heavy loads. Together, the vertebral bodies and discs bear about 80 percent of the load to the spine.

The posterior arch consists of the pedicles, laminae, and processes.

The pedicles are two short cylinders of bone that extend from the vertebral body. Nerve roots branch off the spinal cord and exit to the body between the pedicles of two vertebrae. If the spine becomes unstable, the pedicles may compress the nerve root and cause pain or numbness.

Laminae are two flattened plates of bone that form the walls of the posterior arch. Over time, the laminae may thicken, a process called stenosis. This thickening compresses the spinal cord and/or nerves causing pain or numbness.

Vertebral Anatomy

The articular, transverse, and spinous processes project off the laminae. Ligaments and tendons attach to the processes. The articular processes join one vertebra to another posteriorly.

The transverse processes extend out on either side of the laminae. The spinous process is the bony projection that can be felt through the back of someone’s skin.

Detailed views of a vertebra and vertebral segment.
The drawing to the left represents a top view of a lumbar vertebra.
The drawing to the right is a lateral (side) view of a segment of three lumbar vertebrae.

Curves of the Spine

When viewed from the front or back, the normal spine is in a straight line, with each vertebra sitting directly on top of the other. A side-to-side curve in the spine is called scoliosis.

When viewed from the side, the normal spine has three gradual curves:

• The neck has a lordotic curve; it curves towards the front.
• The thoracic spine has a kyphotic curve; it curves towards the back.
• The lumbar spine also has a lordotic curve.

These curves help the spine to support the load of the head and upper body, and maintain balance in the upright position.

Abnormal Anatomy

Scoliosis: An abnormal spinal condition called scoliosis is shown in this drawing. Scoliosis is a lateral (sideways) curvature of the spine.
Spondylolisthesis: Spondylolisthesis is an abnormal spinal condition in which one vertebra slips or is displaced over another vertebra. The drawing shows spondylolisthesis as a result of a lumbar vertebra (L5) slipping over the sacrum (S1).
Kyphosis: The spinal condition of kyphosis is an abnormal increase in normal kyphotic (posterior) curvature of the thoracic spine which can result in a noticeable round-back deformity.
Lordosis: The spinal condition of lordosis is the abnormal increase in normal lordotic (anterior) curvature of the lumbar spine. This can lead to a noticeable “sway-back” appearance.

Detail

Arthritis

This drawing illustrates degenerative and hypertrophic arthritis between the third, fourth, and fifth lumbar vertebrae, as well as the lumbosacral joint (L5 – S1 disc space). The degeneration of the intervertebral discs has reduced the height of the discs.

There are bone spurs or hypertrophic bone adjacent to the discs and hypertrophic arthritis of the facet joints. This results in reduced range of motion of the spine. Also, the hypertrophic bone and narrowing of the intervertebral foramen can produce nerve root impingement thereby causing back and leg pain, as well as numbness and weakness of leg muscles.

Intervertebral Discs

Intervertebral discs are located between each vertebra from C2 – C3 to L5 – S1. Combined, they make up one-fourth the height of the spinal column. The discs act as shock absorbers to the loads placed on the spine and allow movement of the spine. Movement at a single disc level is limited, but all of the vertebrae and discs combined allow for a significant range of motion.

The intervertebral disc is made up of two components: the annulus fibrosus and the nucleus pulposus. The annulus fibrosus is the outer portion of the disc. It is composed of layers of collagen and proteins, called lamellae. The fibers of the lamellae slant at 30-degree angles, and the fibers of each lamella run in a direction opposite the adjacent layers. This creates a structure that is exceptionally strong, yet extremely flexible.

The nucleus pulposus is the inner gel material surrounded by the annulus fibrosus. It makes up about 40% of the disc. This ball-like gel is contained within the lamellae. The nucleus is composed primarily of loose collagen fibers, water, and proteins. The water content of the nucleus is about 90% at birth and decreases to about 70% by the fifth decade.

Injury or aging of the annulus fibrosus may allow the nucleus pulposus to be squeezed through the annulus fibers either partially, causing the disc to bulge, or completely, allowing the disc material to escape the disc. The bulging disc or nucleus material may compress the nerves or spinal cord, causing pain.

In the early years of life, the discs have a blood supply that nourishes them. In the second and third decades, discs gradually lose this blood supply, until they are avascular. At this point, the disc begins to degenerate, or age. By the age of 50, over 95% of all people will have disc degeneration. The disc begins to lose water content and shrinks. The spine’s range of motion and shock-absorbing ability are decreased. This may result in injury to the nerves and vertebrae, and the aging disc itself may generate pain.

 

Detail

The drawings on the right represent the appearance of a herniated or ruptured disc. Both drawings show the disruption of the annulus fibrosus, the outer ring-like portion of an intervertebral disc.

The tissue located in the center of the intervertebral disc, the nucleus pulposus, is partially extruded from the intervertebral disc. The extruded nucleus pulposus material can exert pressure on nerves thus causing pain, numbness, and muscle weakness due to nerve damage.

Spinal Cord and Nerve Roots

The brain and spinal cord together make up the central nervous system. The spinal cord is located immediately below the brain stem. It extends through the foramen magnum, a hole at the base of the skull.

The spinal cord functions as a sophisticated network that carries information from the outer elements of the body (skin, muscles, ligaments, joints) through the sensory tracts, to the brain. Data is processed there, and new information such as muscle control is sent out through the motor tracts of the spinal cord.

The spinal cord ends as the conus medullaris at the L1 vertebral level, where it branches into the cauda equina, a collection of nerves that extend from the conus medullaris to the sacrum. The conus medullaris nerves float freely in spinal fluid, making it possible to pass a needle safely into the area to draw a sample of spinal fluid or inject drugs, anesthetics, or radiologic substances for x-ray, MRI or CT scan.

Anthroplasty is the surgical reconstruction of a joint to improve function and reduce pain. When vertebral arthroplasty is performed, an artificial disc replaces the existing diseased disc. The artificial disc code range is 84.60 – 84.69.

Laminectomies: Each vertebral level should be coded with procedure code 03.09. Only half of the laminectomies reported last year were principal procedures, meaning the other half were procedures secondary to other spine procedures.

Disc excisions: Each disc that is excised should be reported using code 80.51. The corresponding laminectomy should not be separately reported, because it is necessary to perform a laminectomy to remove the disc. However, if a laminectomy is being performed at a different level, it is acceptable to report code 03.09.

Spinal Fusion

Spinal fusions/refusions may be performed if the vertebrae become unstable (spondylolisthesis), degenerated, fractured, or deformed as with a curvature of the spine. Fusions of the cervical spine are most common and typically involve one or two
vertebra(e). However, fusions of the lumbar spine have more varieties of hardware.

The surgical approach may be through the belly (anterior), the back (posterior), or both (so-called 360° or anterior/posterior). Most cages are placed anteriorly, although L5 – S1 is easier than L4 – L5 because the aortic arch with major blood vessels is between the incision and the spine.

Fusions/refusions: ICD-9-CM procedure codes for spinal fusions do not differentiate instrumented from noninstrumented fusions, nor do they identify the specific vertebra and/or the use of allograft in the fusion space. The “inclusion note” in this section, states instrumentation and bone graft are included in the fusion code. It is possible to code fusions in additional regions (thoracic, cervical, lumbar), and to code both anterior and posterior fusions. The code range for a fusion is 81.00 – 81.08 and refusions 81.30 – 81.39.

An interbody spinal fusion device* may be used when a fusion is performed. This device is often called a cage or a spacer. It can be made of titanium, Polyetheretherketone (PEEK), carbon, etc. This device is coded as 84.51. Interbody devices made of allograft are not reported using code 84.51 and are included in the code for fusion.

Bone graft for spinal fusions is usually taken from the patient’s iliac crest, although allograft or bone substitutes may be mixed with the patient’s bone. Bone harvested from the patient’s iliac crest and locally should be reported using code 77.79. Physicians may choose not to take patient’s bone because of complications and pain associated with the excision. Allograft used in spinal fusions is not reported separately.

Infuse^® Bone Graft consists of two parts: a solution containing rhBMP-2 (recombinant human bone morphogenetic protein 2) and the ACS (absorbable collagen sponge). The protein is a genetically engineered version of a natural protein normally found in small quantities in the body. The purpose of the protein is to stimulate bone formation. Infuse Bone Graft is coded as 84.52.

More than 40 years ago, orthopaedic surgeons determined that the protein extracts required for bone to heal or regenerate in the body were contained within the bone itself. In 1979, Dr. Marshall Urist, a professor in the Department of Orthopaedic Surgery at the University of California at Los Angeles School of Medicine, coined the term “bone morphogenetic protein” (BMP) to describe these proteins.

Instrumentation may be used to stabilize the fusion. The different types of instrumentation include screw/hook and rod systems and plate and screw systems.

Screw/hook and rod systems are typically applied from the back (posteriorly).

Plate and screw systems are most often used in anterior cervical fusions, and occasionally in lumbar fusions. There are specially designed plates for vertebral fractures.

Variations in the instrumentation include titanium vs. stainless steel components, and variable angle vs. fixed screws. Variable angle (or polyaxial, multiaxial) screws allow surgeons to attach the screws to the spine at different angles and make it easier to attach the screws to the rods.

Transverse mechanisms (CROSSLINK^® Plate, transverse mechanism, transverse connector): Longer fusions may become unstable across the vertebral column and so a supporting structure may be used to provide additional stability.

Spinal barriers are designed to reduce scarring after surgery, thus reducing pain and the need for re-operations.

Bone growth stimulators are designed to provide an electric stimulation to the spine, thus improving fusion rates. Insertion of bone growth stimulators is coded as 78.99.

* Wording is taken from ICD-9-CM 2011.

Spinal Surgery Key Terms

A – E

F – K

L – P

S – Z

Brief Summary of Indications, Contraindications, and Warnings for the BRYAN^® Cervical Disc:

The BRYAN^® Cervical Disc is indicated in skeletally mature patients for reconstruction of the disc from C3-C7 following single-level discectomy for intractable radiculopathy and/or myelopathy. The BRYAN^® device is implanted via an open anterior approach. Intractable radiculopathy and/or myelopathy is defined as any combination of the following: disc herniation with radiculopathy, spondylotic radiculopathy, disc herniation with myelopathy, or spondylotic myelopathy resulting in impaired function and at least one clinical neurological sign associated with the cervical level to be treated, and necessitating surgery as demonstrated using computed tomography (CT), myelography and CT, and/or magnetic resonance imaging (MRI). Patients receiving the BRYAN^® Cervical Disc should have failed at least six weeks of non-operative treatment prior to implantation of the BRYAN^® Cervical Disc.

The BRYAN^® Cervical Disc should not be implanted in patients with an active infection or with an allergy to titanium, polyurethane or ethylene oxide residues, active systemic infection or infection at the operating site; osteoporosis defined as a DEXA bone mineral density T-score equal to or worse than -2.5; moderate to advanced spondylosis characterized by bridging osteophytes, marked reduction or absence of motion, or collapse of the intervertebral disc space of greater than 50% of its normal height; marked cervical instability on radiographs (e.g., radiographic signs of subluxation greater than 3.5mm or angulation of the disc space more than 11 degrees greater than adjacent segments); significant cervical anatomical deformity or compromised vertebral bodies at the index level (e.g., ankylosing spondylitis, rheumatoid arthritis, or compromise due to current or past trauma); significant kyphotic deformity or significant reversal of lordosis; or symptoms necessitating surgical treatment at more than one cervical level.

The BRYAN^® Cervical Disc should only be used by surgeons who are experienced in the surgical procedure and have undergone adequate training with the device. A lack of adequate experience and/or training may lead to a higher incidence of adverse events, such as neurological complications.

The safety and effectiveness of this device has not been established in patients with the following conditions: axial neck pain as solitary symptom; not skeletally mature; prior cervical spine surgery, including prior surgery at the index level; facet joint pathology of involved vertebral bodies; active malignancy; Paget’s disease, osteomalacia, or other metabolic bone disease; chronic or acute renal failure or history of renal disease; taking medications known to potentially interfere with bone/soft tissue healing (e.g., steroids); pregnant; unstable cardiac disease; diabetes mellitus requiring daily insulin management; and extreme obesity as defined by the NIH Clinical Guidelines Body Mass Index (i.e., BMI ≥40); less than 21 years of age and were not refractory to at least six weeks of unsuccessful conservative treatment or had signs of progression or spinal cord/nerve root compression with continued non-operative care.

Implanted metal alloys release metallic ions into the body. The long-term effect of these ions on the body is not known. Patients in the clinical study were instructed to use non-steroidal anti-inflammatory drugs (NSAIDs) for two weeks postoperatively. Dosing and frequency were left to the discretion of the physician. It has been reported in the literature that short-term postoperative use of NSAIDs may reduce the instance of heterotopic ossification.

Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.

Please see the package insert for the complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.

Bryan Brief Summary of Indications