Hospitals SpineLine Reimbursement

GET THE LATEST UPDATES AND ALERTS

Sign up to receive updates for important changes to coverage and reimbursement issues as they happen. You can also view our reimbursement updates and alerts page.

The information you provide will be used only to send you information specific to coverage for spinal procedure coverage and major national reimbursement topics.

* Indicates a required field.

First name*

Last name*

Practice / Facility Name*

Title / Role*

E-mail*

Address

City

State

Country/Region*

ZIP Code

Do you agree to receive updates about reimbursement?*

Your information will be protected in accordance with our privacy statement.

Frequently Asked Questions

Lumbar Spinal Fusion in ICD-10-PCS

ICD-10-PCS has a seven character alphanumeric code structure. A code is derived by choosing a specific value for each of the seven characters based on the details of the procedure performed. ICD-10-PCS codes for lumbar spinal fusion are built with the following code table (0SG) for fusion of the lower joints.

Section	0 – Medical and Surgical
Body System	S – Lower Joints
Operation	G – Fusion

Given the first three characters of 0SG, you then select the appropriate 4th character Body Part, 5th character Approach, 6th character Device and 7th character Qualifier based on the details of the procedure.

Section	0 – Medical and Surgical
Body System	S – Lower Joints
Operation	G – Fusion

Body Part	Approach	Device	Qualifier
0 – Lumbar Vertebral Joint	0 – Open	7 – Autologous Tissue Substitute	0 – Anterior Approach, Anterior Column
1 – Lumbar Vertebral Joints, 2 or more	3 – Percutaneous	J – Synthetic Substitute	1 – Posterior Approach, Posterior Column
3 – Lumbosacral Joint	4 – Percutaneous Endoscopic	K – Nonautologous Tissue Substitute	J – Posterior Approach, Anterior Column
3 – Lumbosacral Joint	4 – Percutaneous Endoscopic	Z – No Device	J – Posterior Approach, Anterior Column
0 – Lumbar Vertebral Joint	0 – Open	A – Interbody Fusion Device	0 – Anterior Approach, Anterior Column
1 – Lumbar Vertebral Joints, 2 or more	3 – Percutaneous		J – Posterior Approach, Anterior Column
3 – Lumbosacral Joint	4 – Percutaneous Endoscopic		J – Posterior Approach, Anterior Column

For example, an L4-5 open approach posterolateral fusion with autograft is coded: 0SG0071. An L3-5 open approach posterior interbody fusion with an interbody fusion device is coded: 0SG10AJ. An L5-S1 open approach anterior interbody fusion with allograft is coded: 0SG30K0.

What if the procedure uses a combination of devices to obtain fusion like an interbody device with allograft?

ICD-10-PCS guideline B310c states: "Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:

If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value for the interbody fusion device.
If bone graft is the only device used to render the joint immobile, the procedure is coded with the device value nonautologous tissue substitute or autologous tissue substitute.
If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value autologous tissue substitute."

What if multiple vertebral joints are fused?

ICD-10-PCS guideline B3.10b states that if multiple joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier.

What about the insertion of spinal instrumentation?

The AHA Coding Clinic for ICD-10 3rd Quarter 2014 states "ICD-10-PCS general guideline B3.1b clarifies that components of a procedure specified in the root operation definition and explanation are not coded separately. The explanation in the root operation for fusion states ‘that body part is joined together by fixation device, bone graft, or other means.’ Therefore, the fixation (rods, plates, screws) is included in the fusion and no additional code is assigned."

How is the discectomy coded?

According to AHA Coding Clinic for ICD-10 2nd Quarter 2014, if a provider performs a discectomy with spinal fusion, it should be coded as excision of disc. If, however, the provider documents "total discectomy," it should be coded as disc resection. For example, 0SB20ZZ – Excision of lumbar vertebral disc with an open approach.

What about the excision of bone for grafting?

ICD-10-PCS guideline B3.9 states that if autograft is obtained from a different body part then a separate procedure is coded. For example, 0QB20ZZ – Excision of right pelvic bone with an open approach.

Do you report more than one fusion code when both the anterior and posterior columns of the spine are fused during a ‘360-degree’ fusion procedure?

Yes. More than one fusion code is required because there are different 7th character qualifiers for the anterior and posterior columns of the spine.

Can an interbody fusion device be reported for a posterior column fusion?

No. An interbody fusion device indicates that a fusion procedure is performed in the anterior column of the spine.

Does the insertion of posterior spinal instrumentation alone require the reporting of a posterior column fusion code?

No. Spinal fusion involves some type of bone graft or bone graft substitute. In addition, while the Z character (No Device) is currently available for spinal fusion PCS codes, the ICD-10 Coordination and Maintenance Committee intends to delete value ‘Z-No Device’ from tables 0RG and 0SG, Fusion of Upper Joints and Fusion of Lower Joints.

PMD018328-2.0

DRGs

Common MS-DRGs for Medtronic Spinal Products

5-Year Medicare Payment Trends FY2013 – FY2017

Anterior/Posterior Fusion

MS-DRG	Description	FY'14 (Rel. Wgt)	FY'15 (Rel. Wgt)	FY'16 (Rel. Wgt)	FY'17 (Rel. Wgt)	FY'18 (Rel. Wgt)	FY'14–18 $ Change
453	Combined anterior/ posterior spinal fusion with MCC	$68,118 ( 11.7453)	$65,562 (11.1637)	$67,510 (11.4304)	$64,673 (10.8459)	$58,705 (9.7411)	-$9,413 -13.8%
454	Combined anterior/ posterior spinal fusion with CC	$47,091 (8.0184)	$47,091 (8.0184)	$47,661 (8.0698)	$48,425 ( 8.1210)	$39,153 (6.4968)	-$7,360 -15.8%
455	Combined anterior/ posterior spinal fusion without CC/MCC	$36,469 (6.2882)	$36,707 (6.2503)	$36,579 ( 6.1934)	$37,845 (6.3467)	$30,604 (5.0782)	-$8,865 -16.1%

MS-DRG

Description

FY'14
(Rel. Wgt)

FY'15
(Rel. Wgt)

FY'16
(Rel. Wgt)

FY'17
(Rel. Wgt)

FY'18
(Rel. Wgt)

FY'14–18
$ Change

453

Combined anterior/
posterior spinal fusion with MCC

$68,118
( 11.7453)

$65,562
(11.1637)

$67,510

(11.4304)

$64,673
(10.8459)

$58,705
(9.7411)

-$9,413 -13.8%

454

Combined anterior/
posterior spinal fusion with CC

$47,091
(8.0184)

$47,661
(8.0698)

$48,425
( 8.1210)

$39,153
(6.4968)

-$7,360 -15.8%

455

Combined anterior/
posterior spinal fusion without CC/MCC

$36,469
(6.2882)

$36,707
(6.2503)

$36,579
( 6.1934)

$37,845
(6.3467)

$30,604
(5.0782)

-$8,865 -16.1%

Complex Fusion

MS-DRG	Description	FY'14 (Rel. Wgt)	FY'15 (Rel. Wgt)	FY'16 (Rel. Wgt)	FY'17 (Rel. Wgt)	FY'18 (Rel. Wgt)	FY'14–18 $ Change
456	Spinal fusion exc. cervical with spinal curvature, malignancy, infection, or extensive fusion with MCC	$54,973 (9.5871)	$55,227 (9.4039)	$55,554 (9.4061)	$59,127 (9.9158)	$55,470 (9.2044)	-$131 -0.2%
457	Spinal fusion exc. cervical with spinal curvature, malignancy, infection, or extensive fusion with CC	$37,054 (6.8188)	$40,566 (6.9074)	$41,781 (7.0741)	$42,052 (7.0523)	$41,017 (6.8062)	$1.471 3.7%
458	Spinal fusion exc. cervical with spinal curvature, malignancy, infection, or extensive fusion without CC/MCC	$28,577 (5.1378)	$30,913 (5.2637)	$31,294 (5.2986)	$31,835 (5.3389)	$32,336 (5.3657)	$2,539 8.5%

Lumbar Fusion

MS-DRG	Description	FY'14 (Rel. Wgt)	FY'15 (Rel. Wgt)	FY'16 (Rel. Wgt)	FY'17 (Rel. Wgt)	FY'18 (Rel. Wgt)	FY'14–18 $ Change
459	Spinal fusion except cervical with MCC	$39,532 (6.8163)	$39,163 (6.6686)	$38,659 (6.5455)	$39,076 (6.5532)	$36,388 (6.0381)	-$3,143 -8.0%
460	Spinal fusion except cervical without MCC	$23,327 (4.0221)	$23,490 (6.6686)	$23,457 (3.9717)	$23,789 (3.9894)	$24,196 (4.0149)	$869 3.7%

Cervical Fusion

MS-DRG	Description	FY'14 (Rel. Wgt)	FY'15 (Rel. Wgt)	FY'16 (Rel. Wgt)	FY'17 (Rel. Wgt)	FY'18 (Rel. Wgt)	FY'14–18 $ Change
471	Cervical spinal fusion with MCC	$28,675 (4.9444)	$28,622 (4.8737)	$28,960 (4.9033)	$28,715 (4.8156)	$29,642 (4.9187)	$967 3.4%
472	Cervical spinal fusion with CC	$16,986 (2.9288)	$17,129 (2.9166)	$17,158 (2.9051)	$17,167 (2.8789)	$17,196 (2.8534)	$210 1.2%
473	Cervical spinal fusion without CC/MCC	$13,025 (2.2458)	$13,305 (2.2655)	$13,377 (2.2650)	$13,710 (2.2992)	$13,810 (2.2916)	$786 6.0%

Laminectomy/Discectomy/Dynamic Stabilization*

MS-DRG	Description	FY'14 (Rel. Wgt)	FY'15 (Rel. Wgt)	FY'16 (Rel. Wgt)	FY'17 (Rel. Wgt)	FY'18 (Rel. Wgt)	FY'14–18 $ Change
518*	Back & neck procedures except spinal fusion with MCC or disc device/ neurostimulator	$10,929 (1.8845)	$17,987 (3.0628)	$17,275 (2.9249)	$17,252 (2.8932)	$17,435 (2.8930)	$6,505 59.5%
519*	Back & neck procedures except spinal fusion with CC	$10,929 (1.8154)	$9,671 (1.6468)	$9,925 (1.6845)	$10,235 (1.7165)	$10,871 (1.8038)	-$59 -0.5%
520*	Back & neck procedures except spinal fusion without CC/MCC	$6,317 (1.0893)	$6,693 (1.1396)	$6,976 (1.1812)	$7,349 (1.2324)	$7,814 (1.2966)	$1,496 23.7%
*FY2014 levels are aggregates of former Other Back and Neck Procedures (including artificial disc and XSTOP) DRGS 490-491 ; DRG 519 Is compared to DRG 490

Spinal Procedures with a Neurologic Diagnosis (MDC 1)

MS-DRG	Description	FY'14 (Rel. Wgt)	FY'15 (Rel. Wgt)	FY'16 (Rel. Wgt)	FY'17 (Rel. Wgt)	FY'18 (Rel. Wgt)	FY'14–18 $ Change
28	Spinal Procedures with MCC	$31,514 (5.4339)	$31,694 (5.3968)	$31,713 (5.3695)	$33,058 (5.5439)	$33,499 (5.5586)	$1,984 6.3%
29	Spinal Procedures with CC or Spinal Neurostimulators	$17,582 (3.0782)	$18,542 (3.1573)	$18,042 (3.0548)	$19,011 (3.1882)	$19,729 (3.2737)	$1,877 10.5%
30	Spinal Procedures without CC/MCC	$10,492 (1.1542)	$10,475 (1.7835)	$10,620 (1.7982)	$11,334 (1.9008)	$12,856 (2.1333)	$2,364 22.5%

Assumes payment for a hospital with a wage index and geographic adjustment factor of 1.000. Constant volume year-over-year.

C-Codes

C-Codes for Spinal Devices

Medicare requires hospitals to use device codes in conjunction with procedures that require the implantation of a device that are assigned to a device-intensive APC under the Hospital Outpatient Prospective Payment System (HOPPS). While some instrumented spine procedures are on Medicare's inpatient only list, precluding the assignment of a HCPCS II C-code, other spine procedures may be assigned to a device-intensive APC.

The following list provides some HCPCS II codes that may be applicable to some Medtronic Spinal & Biologic devices:

C1713 – Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable). Implantable pins and/or screws that are used to oppose soft tissue-to-bone, tendon-to-bone, or bone-to-bone. Screws oppose tissues via drilling as follows: soft tissue-to-bone, tendon-to-bone, or bone-to-bone fixation. Pins are inserted or drilled into bone, principally with the intent to facilitate stabilization or oppose bone-to-bone. This may include orthopedic plates with accompanying washers and nuts. This category also applies to synthetic bone substitutes that may be used to fill bony void or gaps (i.e., bone substitute implanted into a bony defect created from trauma or surgery).

C1889 – Implantable/insertable device for device intensive procedure, not otherwise classified

C1776 – Joint device (implantable). An artificial joint that is implanted in a patient. Typically, a joint device functions as a substitute to its natural counterpart and is not used (as are anchors) to oppose soft tissue-to-bone, tendon-to-bone, or bone-to-bone.

Please refer to the list of device category codes on the CMS website.

For further information, please contact the SpineLine^® (hospital and physician coding/billing support) at:

(877) 690-5353 or
spinalcodinghospital@medtronic.com

PMD018327-3.0