Physicians 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*

Email *

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.

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 (e.g., "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.

CPT-Modifier List

Modifier -22 Unusual Procedural Services

Used to alert payers to unusual circumstances or complications encountered during a procedure, when the services provided are greater than usually required.
Payers watch use of this modifier very carefully since it has been widely abused. Do not use with E/M codes.
CMS contends that the slight extension of a procedure does not warrant the -22 modifier. The circumstance must involve significant increase in physician work.
Use modifier -22 when:
- Complications cannot be identified by a separate code and there is a significant increase in physician work.
- The procedure is lengthy and unusual.
- Work and effort is increased by approximately 30-50% of what would normally be required due to unusual circumstances.

Send a cover letter and report with the claim documenting unusual circumstances. Do not use generalizations, be specific. For example, it is helpful to state that the procedure took three hours and normally only takes one hour, then explain how and why the work was increased.
The Medicare carrier may increase reimbursement if sufficient documentation is submitted.

Modifier -26 Professional Component

Used to denote the professional services of a physician when the service has both a professional and technical component.
Also used by physicians to denote interpretation of diagnostic tests.
CMS indicates that payment is affected by use of this modifier; some procedures have a professional and technical component and the global billing may be divided into these components.

Modifier -32 Mandated Services

Attach to mandated consultation and/or other services. These services are flagged because they are required by a third party, e.g., a court of law, agency, or insurance entity.
Many Medicare carriers will require use of HCPCS Level II modifier SF (second opinion ordered by a PRO or professional review organization) or SM (second surgical opinion) or SN (third surgical opinion).
CMS has indicated that use of this modifier does not affect payment.

Modifier -50 Bilateral Service

A bilateral procedure is defined as the same procedure being performed on both sides of the body.
Do not attach this modifier to CPT surgical procedures that contain the language, "one or both," (e.g., 64776 – Excision of neuroma; digital nerve, one or both, same digit); or "unilateral or bilateral," (e.g., 63047 – Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis), single vertebral segment; lumbar).
Typically, the allowance for bilateral procedures is 150% of the unilateral allowance. However, there are some payers who will allow 100% for each side. Payment by CMS is 150% for procedures that allow this modifier. The bilateral indicator of "1" in the Physician Fee Schedule denotes 150% payment for bilateral procedure.
There are multiple ways to report a bilateral procedure. Contact your payer for their preference.

Modifier -51 Multiple Procedures

Use this modifier to denote more than one medical/surgical procedure (multiple procedures other than E/M) being performed by the same physician on the same day at the same operative session. The major procedure with the highest RVU is listed first and is reimbursed in full. Secondary or lesser procedures may be listed next with modifier -51.
CMS pays 100% for the first procedure and 50% for the second through fifth procedures. Any other multiple procedure will be paid after carrier review.
When billing, do not reduce the charge amount; allow the payer to reduce payment.
Be careful if you use the -51 modifier with procedure codes with phrases like "each additional" or "list in addition to," because use of the -51 modifier may result in an unintended further reduction of the payer's allowance. Add-on procedures, such as "63048 – Each additional segment," are exempt from usage of modifier -51 per CPT.

Modifier -52 Reduced Services

Use when the physician reduces or eliminates a portion of the procedure as described within a certain CPT code, at the physician's discretion. Modifier -52 is reported in addition to the procedure code.
Do not use with E/M codes.
Examples: Procedures that are normally performed bilaterally but are only performed on one side.
Use of an ICD-9-CM diagnosis code will identify the reason for reduction of service. See code range V64. (Persons encountering health services for specific procedures not carried out.)
CMS payment is based on the extent of the procedure performed. Submit documentation with the claim.

Modifier -53 Discontinued Procedure

A surgical or diagnostic procedure may have been started but discontinued due to extenuating circumstances, or those that threaten the well-being of the patient. This circumstance is reported by adding the modifier -53 to the code for the discontinued procedure.

Modifier -54 Surgical Care Only

Use when one physician provides surgical services and another provides preoperative and/or postoperative care
The medical record should contain a written agreement for transfer of care
Modifier -54 generally includes the preoperative care that a surgeon renders the day before surgery
CMS indicates that payment will be limited to the preoperative and intraoperative services only.

Modifier -55 Postoperative Management Only

Physician provides only the postoperative care and is paid the postoperative percentage of the global service, because another physician has performed the surgical procedure.
Do not attach this to an E/M service code; it is only attached to the surgical or medical procedure code (include the date the surgery was performed).
May only be billed after the first postoperative visit has been performed.
CMS indicates that payment is limited to the amount allotted for postoperative services only.

Modifier -56 Preoperative Management Only

Attach this modifier to the surgical or medical procedure code.
Use to report the preoperative component when another physician was responsible for the intraoperative and postoperative care of the patient. This modifier is rarely used.
Do not use this modifier for Medicare claims. Payment for this component is included in the allowable for the surgery. If another physician performed the surgery, report only an E/M service code for the level of care provided.

Modifier -57 Decision to Perform Surgery

Identifies an E/M service that resulted in the decision for surgery. For Medicare the preoperative global period is the day before or day of surgery.
Attach to an E/M service code, not the surgical or medical procedure code.
CMS expects this modifier to be used when the surgery has a 90-day postoperative period. Use of this modifier allows payment of the E/M service in addition to the surgical or medical procedure.

Modifier -58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Use this modifier when a procedure is performed during the postoperative period and was one of the following:
- Planned prospectively at the time of the original procedure
- More extensive than the original procedure
- Used for therapy following a diagnostic surgical procedure that has a global period
If a less extensive procedure fails and a more extensive procedure is required, the second procedure should be billed with the -58 modifier.
CMS has clarified that those surgical procedures that contain the language, "one or more sessions" (e.g., codes 67141-67228), should not be modified with -58.
CMS has indicated that use of this modifier does not affect payment.

Modifier -59 Distinct Procedure Service

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.
Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent the following situations not ordinarily encountered or performed on the same day by the same physician:
- Different session or patient encounter
- Different procedure or surgery on the same day
- Different site or organ system
- Separate incision/excision
- Separate lesion, or separate injury (or area of injury in extensive injuries)
When another already established and more descriptive modifier is available, it should be used rather than -59, unless the use of modifier -59 best explains the circumstances.
Multiple services provided to a patient in the same day by the same provider may appear to be incorrectly coded, when in fact the services may have been performed as reported. Because you cannot easily identify these circumstances, a modifier was established to permit claims of such a nature to bypass correct coding edits.
Modifier -59 may be used to identify those circumstances where a procedure designated as a "separate procedure" is carried out independently, or considered unrelated or distinct from other procedures/ services provided at that time.
Modifiers for selective identification of subsets of modifier 59: XE Separate Encounter, XS Separate Encounter, XP Separate Practitioner, XU Unusual Non-Overlapping Service.

Modifier -62 Two Surgeons

Used when two surgeons perform a single procedure together. If each surgeon is performing a different procedure during the same operative session, then modifier -62 is not necessary for most carriers.
The -62 modifier should only be appended to a single definitive primary procedure and any associated add-on code(s) as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the same procedure code with the co-surgery modifier.
Do not use this modifier to describe the services of an assistant surgeon. If a co-surgeon acts as an assistant during additional procedures in the same operative session, those services should be reported using modifiers -80 or -82 (as appropriate).
Each surgeon must dictate his or her own operative report.
Payment from CMS is increased to 125% and each surgeon receives 62.5% of the approved allowable. Some surgical procedures will allow payment for a co-surgeon while other procedures will not allow cosurgery payment at all.
The modifier -62 may not be reported for procedures involving three or more surgeons at the same surgical session. Modifier -66 should be used to describe this involvement.

Modifier -66 Surgical Team

Use this modifier to identify a highly complex or intricate procedure requiring the concomitant services of more than two physicians, often of different specialties, e.g., organ transplant or multi-trauma patients.
Each surgeon submits his services with modifier -66.
Most payers automatically submit these claims to medical review for determination of payment to each provider. Medicare sends these claims to the carrier's Medical Director for payment decision.

Modifier -76 Repeat Procedure by Same Physician

Use to report a repeat procedure by the same physician performed subsequent to the original procedure on the same day or during the postoperative period.
Used to prevent claim denial for duplicate billing.
CMS has indicated that this modifier does not affect payment; it is for informational purposes only.

Modifier -77 Repeat Procedure by Another Physician

Identical to Modifier -76, except that the physician performing the service is different from the one who performed the original service.
CMS has indicated that this modifier does not affect payment.

Modifier -78 Return to the Operating Room for a Related Procedure During the Postoperative Period

"Operating room" is defined by CMS as a place of service specifically equipped and staffed for the sole purpose of performing procedures. This includes cardiac catheterization suites, laser suites and endoscopy suites. It does not include a patient room, a minor treatment room, a recovery room or an intensive care unit.
Use this modifier to report the treatment of a problem that requires a return to the operating room and is related to the original procedure, e.g., medical, surgical or mechanical complications.
CMS will pay the intraoperative service amount of the code and recognizes this modifier when attached to procedures with a 10- or 90-day global period. A new postoperative period does not begin with the use of modifier -78.
CMS allows full payment for complications treated by another physician if expertise beyond that of the first surgeon is necessary to treat the complications. In this case, no modifier is needed and only the allowance for the intraoperative period will be allowed.

Modifier -79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period

Similar to modifier -78, except that the return to the operating room is for an unrelated procedure, and this modifier specifies that the physician is the same one who performed the original surgery.
The diagnosis code should reflect that the procedure is unrelated.
With -79, a new postoperative period begins and payment should be the full amount.
Do not use to denote a return to the operating room for complications due to the original surgery.
CMS has indicated that use of this modifier does not affect the payment amount.

Modifier -80 Assistant Surgeon

Used to identify the services of an assistant surgeon or resident surgeon at a teaching facility.
Payers will reimburse a small portion of the surgical fee to the assistant. (Private payers reimburse approximately 20-25% of the surgical fee to the assistant, while Medicare pays 16% of the Medicare fee allowed amount). Most payers have lists of procedures for which they will allow payment to an assistant.
Physicians are prohibited from charging a Medicare beneficiary for an assistant-at-surgery when a procedure is not covered.

Modifier -81 Minimum Assistant Surgeon

Used to identify those services of a surgical assistant with no "hands on," or a second or third assistant, that falls into the category of minimum service rendered.
Not covered by CMS except in extreme cases. Check other third-party payers to determine their reimbursement policy.

Modifier -82 Assistant Surgeon (When Qualified Resident Surgeon Not Available)

Use this modifier when no qualified resident surgeon is available to assist or there is not an appropriate training program for the medical specialty that is required to perform the procedure.
CMS has strict guidelines regarding the use of an assistant in teaching facilities. A certificate should accompany the claim which states:
- "I understand that section 1842 of the Social Security Act prohibits Medicare Part B payment for the services of assistants-at-surgery in teaching hospitals when qualified residents are available to furnish such services. I certify that the services are subject to post-payment review by the Medicare carrier."

Modifier -AS Ancillary Personnel

AS indicates assistant surgery performed by PA, NP or CNS.

HCPCS Level II Modifiers

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.

Sources

National Correct Coding Policy Manual for Part B Medicare Carriers, Health Care Financing Administration, April 2007.

Modifiers Made Easy, Medicode, 2002.

FAQ

Frequently Asked Questions

Where can the Medicare Physician Fee Schedule be found?

The Physician Fee Schedule can be found on the CMS Web site.

DOES MEDTRONIC OFFER ANY COURSES ON CODING FOR SPINAL PROCEDURES?

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 Series^SM you can:

Get a basic overview of spine anatomy, spinal instrumentation and surgical procedures
Clarify the correct use of modifiers in complex spine surgery coding
Identify new technologies and common documentation challenges
Learn spinal CPT and ICD-9 coding through working with case examples
Understand the pros and cons of the development of a spine center
Gain knowledge about negotiating managed care contracts for your physician practice
Ask questions and receive answers in real time

Contact the SpineLine^® at 1-877-690-5353 to obtain a schedule of upcoming courses, or go to our online registration.

WHAT IS THE APPROPRIATE CODE FOR REPORTING CORNERSTONE, TANGENT, PRECISION AND OTHER TRICORTICAL ALLOGRAFTS?

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.

HOW MANY TIMES PER ENCOUNTER CAN AN ALLOGRAFT FOR SPINE SURGERY BE REPORTED?

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.”

WHAT CODE SHOULD BE REPORTED FOR A CERVICAL LAMINOPLASTY PROCEDURE?

CPT code 63050 or 63051 is appropriate depending on whether there is reconstruction of the posterior bone elements.

Can codes 22630 and 63047 be reported together?

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.”

CAN YOU EXPLAIN WHEN CODE 22551 SHOULD BE REPORTED?

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.

HOW IS A LUMBAR DISCECTOMY PROCEDURE CODED WHEN IT IS PERFORMED WITH THE METRX SYSTEM?

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.

HOW IS A DIRECT LATERAL INTERBODY FUSION DLIF OR AN OBLIQUE LATERAL INTERBODY FUSION OLIF CODED?

22558

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

WHICH CPT CODE IS APPROPRIATE FOR THE RIALTO SI FUSION SYSTEM (27280, 27279)?

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.

WHAT IS THE MEDICARE NATIONAL CORRECT CODING INITIATIVE?

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.

How to Use the Medicare National Correct Coding Initiative (NCCI) Tools (PDF)

Who can I contact for additional questions?

Contact the Reimbursement Support Center, 866-743-1220.

spinalcodingmd@medtronic.com or spinalcodinghospital@medtronic.com

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