Physicians SpineLine Reimbursement
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Guides to assist with coding and reimbursement for new technologies in spine:
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.
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.
To use the calculator, follow the instructions found in the pdf titled “Help with Physician Fee Schedule Search” located at the bottom of the page when you open the link below.
For additional information or assistance, feel free to email the SpineLine®.
The information included by CPT code is the detail of RBRVS relative values, applicable ICD-10 diagnosis codes (examples), the Medicare Status Indicators and coding tips specific to the code selected.
The information included in the Medicare Status Indicators is the timeframe for the global surgical package, professional and technical component indicators, if multiple procedure concept is applicable, if bilateral concept is applicable, if an assistant at surgery is applicable, if payment for co-surgeons is permitted, if payment for team surgeons is permitted, physician supervision and billable medical services.
Please refer to the Key for Medicare Status Indicators (PDF, 64 KB) to understand the codes utilized in the Medicare Status Indicators.
Be aware that different payers have different rules and policies regarding coding and billing. Except for government programs like Medicare and Medicaid, there are no laws or regulations governing what a payer can or cannot do. Each payer sets its own policies and procedures without reference to what any other payer does.
Our Coding Tips reference the most common rules and policies, which are often those of Medicare. Although many payers ultimately adopt the same policies and procedures as Medicare, some never do.
For questions regarding the codes or indicators, please contact SpineLine®, Medtronic Coding and Reimbursement Support, at:
An integral part of HCPCS is the modifiers. In order to expand the information provided by the five-digit CPT codes, a number of modifiers have been created by the AMA, CMS, and local Medicare carriers. These modifiers, in the form of two symbols, either numbers, letters, or a combination of each, are intended to convey specific information regarding the procedure or service to which they are appended. Modifiers are attached to the end of a HCPCS/CPT code to indicate that a service or procedure described in the code's definition has been modified by some circumstance.
As with the five-digit CPT codes, the use of modifiers (either AMA/CMS or locally defined modifiers) requires explicit understanding of the purpose of each modifier. It is also important to identify when the purposes of a modifier have been expanded or restricted by a third-party payer.
Within the context of multiple services reporting, without the addition of an appropriate modifier, the provider may appear to be engaging in the practice of "unbundling." The appropriate use of modifiers indicates that the services were performed under circumstances that did not involve this practice at all.
There are three levels of modifiers within the HCPCS coding system. Level 1 (CPT) and Level II (HCPCS Level II) modifiers are applicable nationally for many third-party payers and all Medicare Part B claims. Level I or CPT modifiers are developed by the American Medical Association (AMA). HCPCS Level II modifiers are developed by CMS. Level III modifiers are unique to each Medicare Part B carrier and begin with an alpha prefix of S, E, X, Y, Z (eg, "WU" Purchased Diagnostic Test; Utah).
There will be times when the coding and modifier information issued by CMS differs from the AMA's coding advice in the CPT manual regarding the use of modifiers. A clear understanding of the payers' rules is necessary in order to assign the modifier correctly.
AS indicates assistant surgery performed by PA, NP or CNS.
Use these modifiers when submitting Medicare claims and for other payers who recognize Level II modifiers.
GA – Waiver of liability statement on file.
GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
GZ – Item or service expected to be denied as not reasonable and necessary.
The modifiers GA, GY and GZ are used to alert Medicare that the patient's claim is expected to be denied by Medicare or that the patient signed a waiver indicating they understand responsibility for payment.
GC – This service has been performed in part by a resident under the direction of a teaching physician.
GE – This service has been performed by a resident without the presence of a teaching physician under the primary care exception.
The modifiers GC and GE are to be used in teaching physician situations.
LT – Left Side – Used to identify procedure performed on the left side of the body.
RT – Right side – Used to identify procedure performed on the right side of the body.
NOTE: This is not a complete listing. Refer to your HCPCS Level II manual for a complete listing and comprehensive descriptions.
National Correct Coding Policy Manual for Part B Medicare Carriers, Health Care Financing Administration, April 2007.
Modifiers Made Easy, Medicode, 2002.
The Physician Fee Schedule can be found on the CMS Web site.
Yes. It’s no longer necessary to travel to a classroom in order to stay abreast of changes in the industry. Now it’s possible to go online and learn about the latest developments in the business of spine care, coding changes, regulations, and documentation requirements because Medtronic provides live, interactive programs free of charge throughout the year.
Through the Spine Academy Learning SeriesSM you can:
Contact the SpineLine® at 1-877-690-5353 to obtain a schedule of upcoming courses, or go to our online registration.
Per the February 2005 edition of CPT Assistant, all structural allograft bone used for spine surgery should be coded as 20931. Threaded bone dowels and machined allograft are coded as 20931.
CPT Assistant guidelines state each allograft for spine surgery code can be reported once per operative session regardless of the spinal levels to which the allograft is placed. January 2004 CPT Assistant states, “Each type of bone graft code (20930–20938) may be reported one time for a spinal procedure, regardless of the number of vertebral levels being surgically fused.”
CPT code 63050 or 63051 is appropriate depending on whether there is reconstruction of the posterior bone elements.
According to the National Correct Coding Initiative Policy Manual for Medicare Services “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.”
This code combines both the anterior cervical fusion procedure and the anterior cervical discectomy (including decompression) procedure. For traditional anterior cervical discectomy and fusion (ACDF) cases, code 22551 should now be reported instead of 22554 and 63075.
Per CPT, codes 22554 and 63075 should not be reported together even if the procedures are performed by separate surgeons. Code 22551 should be reported if the anterior cervical fusion and anterior cervical discectomy are performed at the same level during the same session.
CPT code 63030 may be appropriate for an open procedure when there is continuous direct visualization through the surgical opening. Code 63035 would be assigned in addition to the primary procedure for each additional interspace. 62380 may be appropriate for an endoscopic decompression when there is continuous direct visualization through an endoscope. For a bilateral procedure, report with modifier 50. CPT guidelines define direct visualization as “Light-based visualization; can be performed by eye, or with surgical loupes, microscope, or endoscope.” For percutaneous decompression performed with indirect visualization without the use of any device that allows visualization through a surgical incision, see 62287, 0275T. Code 62287 is used to report percutaneous decompression of the nucleus pulposus using needle-based technique.
|22558||Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar|
CPT code 27279 is appropriate for the Rialto SI Fusion System: Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (For bilateral procedure, report 27279 with modifier 50).
Code 27280 is used to report open arthrodesis of the sacroiliac joint. There are clinical examples of 27279 & 27280 published in CPT Changes 2015 that may also help distinguish the difference between these two codes.
The Medicare National Correct Coding Initiative (NCCI) (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. NCCI code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.
In addition to code pair edits, the NCCI includes a set of edits known as Medically Unlikely Edits (MUEs). An MUE is a maximum number of Units of Service (UOS) allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single beneficiary.
Contact the Reimbursement Support Center, 866-743-1220.
The material presented in these FAQs is provided to our customers to assist them in obtaining correct and appropriate coverage and reimbursement for healthcare goods and services. To the best of our knowledge, the information contained within was correct as of the date of publication. However, there can be no assurances that it will not become outdated, without notice from Medtronic, or that the government or other payers may not differ with the guidance contained in the FAQs. The responsibility for correct coding, reimbursement submissions, and following device labeling lies with the healthcare provider. We urge you to consult with your coding advisors to resolve any billing questions that you might have.
Current Procedural Terminology (CPT) is copyright 2016 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. CPT® is a trademark of the American Medical Association. PMD018980.1.0