Coding Committee Update

Matthew D. Hepler, MD
Coding Committee Chair

Coding Posterior Interbody Fusion with Decompression
(the Byzantine world of medical coding)

One of the most frequent coding controversies over the last several years has been how to properly code a posterior interbody fusion (22630 or 22633) with a decompression (laminectomy/63047) at the same level. This is an important issue as lumbar interbody fusions and decompressions are some of the most common spine procedures performed and improper coding can lead to CMS audits. More interestingly, exploring this “coding conundrum” in detail helps unveil some of the mechanisms and entities that have come to govern the byzantine process of medical coding.

The primary codes involved include 22630, 22633, and 63047 (for simplicity sake we will not consider some of the add on codes frequently performed in these procedures). The CPT code descriptions are as follows:

22630
Arthrodesis, posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar.

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, lumbar.

63047
Laminectomy, facetectomy, and foraminotomy (unilateral or bilateral) with decompression of spinal cord, equine, and/or nerve root(s) (eg spinal or lateral recess stenosis) single vertebral segment, lumbar.

 

CPT Guidelines

One of the first distinctions to recognize is that arthrodesis codes are in the Musculoskeletal System chapter of CPT (22590-22634) and posterior decompression codes are in the Nervous System section of CPT (63001-63066). These are different organ systems and CPT has, logically, always maintained it is appropriate to include the additional code for a decompression when performed at the same level as a fusion, even though it may be through the same incision. So for example a spondylolisthesis with severe stenosis may be treated with a postero-lateral fusion (22612) and a laminectomy  (63047-51). Remember stand alone codes include the work for the 90 day global period as well as the intra operative work; modifier 51 (multiple procedures) allows additional stand alone procedures which are “discounted” to appropriately represent the additional intra operative work involved (the work RVUs for the 90 day global already accounted for by the first, highest RVU valued primary code).

This is simple enough in the above example when the primary procedures involve distinctly different organ systems. The posterior interbody codes (22630 and 22633) are more complicated because they require some degree of decompression/laminectomy to perform the interbody fusion even though the original vignette used to create the code was for a revision fusion procedure with minimal signs of nerve root dysfunction. Attempts were made to clarify this distinction early on with the CPT editorial change: “laminectomy and/or discectomy sufficient to prepare the interspace (other than for decompression).

So for example a patient undergoing a posterior interbody fusion with leg pain due to lateral recess stenosis/HNP would not justify the additional laminectomy code since the work involved in removing portions of the lamina, facet and disc are included in the interbody procedure. This is also the case when the stenosis is contralateral to a single sided TLIF approach since the vignette for the posterior interbody codes includes a bilateral approach (the vignette is the specific clinical scenario used to create a new code).

However, CPT guidelines clearly state that additional decompression beyond the necessary laminectomy, facetectomy, or discectomy to access the interspace may be separately reported. So for example a patient undergoing an interbody fusion with severe canal and/or foraminal stenosis who requires a complete laminectomy for decompression beyond what is necessary to prepare the interbody space for fusion would report 22630/22633 with 63047. This might include modifier 51 multiple procedures or modifier 59, distinct procedural service (more on this later).  You must, of course, provide adequate documentation in the operative report supporting the need for and performance of any such distinct or additional procedures.

 

Medicare Guidelines (the Byzantine twist)

Although CPT guidelines clearly state that additional decompression beyond that necessary to prepare the disc space may be reported separately (and many payors follow these CPT rules), CMS has disregarded them and prohibited payment for 63047 with 22630/22633 at the same level since 2015.  To understand how we arrived at this conflicting set of guidelines we have to examine how CMS adopted the use of CPT codes (which are owned and maintained by the AMA) while developing its own software (NCCI) to regulate their use (see Modifer 59 SRS newsletter August 2016).

NCCI (National Correct Coding Initiative), CMS’s national editing software system, was developed in the 1990s to detect and prevent “unbundling (billing multiple procedure codes when one code is more appropriate). These NCCI edits apply only to services that are performed on the same day, for the same patient, and billed by the same physician. These edits identify an exhaustive list of code pair combinations that generally should not be reported together by a provider on the same day of service. They further specify combinations which should: never be reported together (0), that may be reported together in special circumstances with an appropriate modifier (1), or are mutually exclusive (ME). In 1999 the NCCI Policy Manual for Medicare Services implemented edits for code pairs 22630 and 63047, which were updated in 2012 to include 22633 and 63047 and again in 2015. The January 2015 NCCI edit guideline states:

“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.”

Multiple efforts were made by various spine group coding organizations to resolve the conflict between the CPT and CMS/NCCI guidelines but CMS has elected not to overturn the edit.

More recently, the October 2016 CPT assistant article stated CPT codes 63047 and 22633 may not be reported together at the same interspace. NASS, CNS, AANS, and ISASS wrote an erratum which AMA has denied and efforts to appeal have been unsuccessful to date as there in no appeal process.

 

In Summary

As noted previously CMS guidelines are in direct conflict with CPT guidelines regarding the combination of posterior interbody fusion with decompression at the same level. As a result coding these procedures has been dependent on the guidelines of the specific payer.

For Medicare/Medicaid (CMS) you may code for 22630/22633 with 63047 to document the work performed. CMS will not pay for the decompression (63047) for the reasons explained and this denial should not be repealed. Also, CMS guidelines indicate you should not append a modifier to this coding combination.

Payers that follow CPT guidelines have permirred a laminectomy at the same level as a posterior interbody fusion with appropriate documentation. In these cases it was appropriate to append modifier 59 to indicate a distinct organ system or modifier 51, multiple procedures according to each payers recommendation. More recently, CPT assistant publication states decompression cannot be reported with interbody fusion at the same level; therefore anticipate payers will begin to deny this as well.

 

Reference:

Laminectomy and Interbody Fusion Confusion.
John Kevin Ratliff, MD, FAANS | Departments | Coding Clarity
AANS Neurosurgeon: Volume 25, Number 1, 2016

Spine Surgery Quandary: Posterior Lumbar Interbody Fusion
When do you bill 63056-59 with 22633, rather than 63047-59?
By Kim Pollock, RN, MBA, CPC, CMDP
AAPC Spine Surgery, June 2016

A Timeline of Posterior Lumbar Interbody Fusion and Decompression of Nerve Roots: Can Posterior Lumbar Interbody Fusion and Decompression Be Reported Together at the Same Interspace?
R. Dale Blasier, MD, Christopher Kauffman, MD, Paul Saiz, MD, NASS Coding Committee
NASS Spineline, April 2016

To access past Coding Corner articles in our Members' Only section of the website, please click here.

 

Chair: Matthew D. Hepler Committee: Shay Bass; Jahangir K. Asghar (C); Judson W. Karlen (C); Barton L. Sachs, Chair Elect; Michael S. Chang; Walaa Elassuity; R. Dale Blasier, Advisory; Richard J. Haynes, Advisory