The American Medical Association’s (AMA’s) Common Procedural Terminology (CPT) 2008 (CPT 2008) includes a number of spine-code changes, including revisions, additions, and clarifications, that can affect the spine surgeon’s bottom line. New and revised CPT codes are designated with a triangle symbol: p. Additionally, several instructional comment changes in the Spine section of CPT are noted with sideways triangle symbols: ut.
Spine-graft codes andinstrumentation changes
Two changes this year apply to the spine-graft codes 20930-20938. First, a guideline change in the Grafts section specifically lists which CPT codes may be used with the graft codes (20930-20938). For example, CPT code 20930 has the following reference, “Use 20930 in conjunction with 22319, 22532-22533, 22548-22558, 22590-22612, 22630, 22800-22819.” Although it has always been correct to report these allograft and autograft codes in conjunction with the arthrodesis codes, the AMA has concretely reinforced this practice with the addition of specific guidelines for each allograft or autograft code used for the spine.
This leads to the second change—designating spine-graft codes as “add-on” CPT codes, indicated by the + symbol. Previously, the spine-graft codes were designed as “exempt from modifier 51” by the Ø symbol. This change actually makes no difference, because the spine-graft codes were never designated as definitive procedure codes. So, whether the code is “add-on” or “exempt from modifier 51” really doesn’t affect payment. Most importantly, payors should reimburse the full allowable for both add-on codes (+) and codes exempt from modifier 51 (Ø). You should not see payment differences due to the CPT symbol change on the spine-graft codes, but you should pay attention to your reimbursements to ensure proper payments.
Similar changes and guidelines were added for the instrumentation codes, which also became add-on codes instead of exempt codes. As with the graft/implant codes, the AMA has specifically indicated which primary codes may appropriately have instrumentation add-on codes. For example, the definition of CPT code 22840 was rewritten to support the change from exempt to add-on status with the addition of the phrase “list separately in addition to code for primary procedure.”
For each individual instrumentation code, the AMA also lists the appropriate primary codes. CPT code 22840, for example, now reads, “Posterior or non-segmental instrumentation (eg, Harrington rod technique), pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation (list separately in addition to code for primary procedure).” The following guideline change is added to the definition of this code.
“u(Use 22840 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 22590-22612, 22630, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307.)t
u(For insertion of posterior spinous process distraction devices, see 0171T, 0172T.)t” The AMA has deleted any reference to “submitting without modifier 51” with these two code groupings because they are now add-on codes, rather than exempt codes.
Spine-section instruction comments
The beginning of the Spine (Vertebral Column) section of CPT 2008 (prior to code 22010) includes new guidelines. The following two new guideline changes describe use of the instrumentation codes: “Within the spine section, instrumentation is reported separately and in addition to arthrodesis” and “Instrumentation procedure codes 22840-22848 and 22851 are reported in addition to the definitive procedure(s).” This revision deletes the reference to reporting without modifier 51 because the codes are no longer exempt codes.
Another new guideline reads, “When arthrodesis is performed in addition to another procedure, the arthrodesis should be reported in addition to the original procedure with modifier 51 (multiple procedures).” This change also addresses the use of instrumentation and bone grafts as add-on codes.
Although these guidelines are new to CPT 2008, the approach mirrors the instructions in the AAOS-sponsored coding courses offered by KarenZupko & Associates.
Another new guideline clarifies when to report the osteotomy codes. This change will help reduce confusion among spine surgeons who mistakenly report an osteotomy code (e.g., 22210-22226) when the definitive procedure is actually an arthrodesis with instrumentation. The following CPT guideline confirms that an osteotomy code should be used when part of the vertebral segment is removed to correct a spinal deformity: “Spinal osteotomy procedures are reported when a portion(s) of the vertebral segment(s) is cut and removed in preparation for re-aligning the spine as part of a spinal deformity correction.”
Three new osteotomy codes (22206-22208) describe lumbar or thoracic three-column osteotomies or pedicle-subtraction osteotomies. The guidelines instruct the physician to report these procedures in addition to the arthrodesis. Refer to page 88 of CPT 2008 for additional guideline information for appropriately reporting the osteotomy codes at the same time as other spinal procedures.
Arthrodesis code and exploration of spinal-fusion changes
Additional guideline changes were made to exclude the reference to reporting instrumentation and graft codes without modifier 51 for arthrodesis and exploration of spinal fusion.
These guidelines can be used to appeal payor denials for CPT code 22830 (Exploration of spinal fusion) in addition to “other definitive procedures, including arthrodesis and decompression.” Although no change was made to this guideline related to the reporting of the exploration of fusion with other more definitive procedures, payors commonly deny the exploration of fusion as bundled. This documentation in CPT 2008 can be used to appeal payor denials of 22830 in situations in which an exploration was performed and followed by refusion of the same two vertebral segments.
Category III codes for posterior spinous-distraction device insertion
The AMA added the two codes that missed the submission deadline date for publication in CPT 2007. In 2006, the AMA introduced the following two Category III codes, which became effective January 1, 2007: 0171T for “Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level” and +0172T, the corresponding additional level code, which is listed separately. An example of this procedure is placement of an interspinous implant for the treatment of spinal stenosis.
Category III codes are temporary codes for emerging technology, services, and procedures. When Category III codes are introduced, you can no longer use an unlisted procedure code to report the service.
Payors’ reimbursement policies for Category III codes differ. Typically, obtaining third-party reimbursement for any procedures considered “investigational” is difficult. Be sure to obtain written prior approval from the insurance company for these procedures and verify reporting preferences.
The new 2008 spine codes and guideline changes provide you with better definitions of when and how to report multiple spinal procedures during the same operative session. The additional guideline changes arm your billing staff with the opportunity to submit appeals to payors using official source documentation to support an inappropriate or unfounded denial or incorrect bundling of services.
As with the change to add-on code status for the spine-graft codes, payor reimbursement should not change due to the add-on code-status change for instrumentation codes. Watch those explanations of benefits carefully and appeal underpayments.
Mary LeGrand, RN, MA, CPC, CCS-P, is a consultant with KarenZupko & Associates.