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Device dilemma: How to code new technology in spine surgery
Daniel Refai
Spine surgery is continually evolving with new technology. These new technologies allow us to provide better care for our patients. However, they also present coding challenges. Teri Romano, RN, MBA, CPC, and Kim Pollock, RN, MBA, CPC, describe common coding dilemmas in this issue of Spine Surgery Today.
Daniel Refai, MD
Associate Editor, Neurosurgery
New devices for spine fixation and instrumentation seem to appear every day. Integrating these new devices into your surgical practice is considerably easier than deciding how to code and get paid for this new technology.
Some guidance is available from national neurosurgical, orthopedic and spine societies, as well as from the American Medical Association (AMA) in its various CPT publications. Look to these official sources to guide you in coding for any new spine technology.
CPT codes
There are three potential types of CPT codes to report placement of a new spine device:
1. a Category I CPT code,
2. a Category III CPT code, or
3. or an unlisted code.
A Category I CPT code is a standard five-digit numerical code used for most spine fixation and instrumentation devices. The Figure lists the most common Category I instrumentation codes. A Category I code designates that a device is FDA approved, consistent with current medical practice and performed frequently by many physicians in the United States. If the configuration and use of a newly available device is consistent with the description and intent of an existing Category I CPT code, then that code may be reported for the device.
The most common Category I instrumentation codes are shown. A Category I code designates that a device is FDA approved, consistent with current medical practice and performed frequently by many physicians in the United States.
Image:Romano T, Pollock K
Some new devices do not meet the description or intent of a current or an existing Category I code. In this case, the AMA may decide to develop a Category III. Category III codes, often referred to as “T” codes, are four-digit codes followed by the letter T. The procedures and devices described by a Category III code may not yet be FDA approved, are not yet performed routinely across the country, or are not yet supported by the peer-reviewed, published data. Since most Category III codes are not assigned a fee by Medicare, payers determine whether to provide reimbursement for a Category III code. Practices should always obtain pre-authorization prior to performing a procedure or placing a device that is reported with a Category III code.
Not every device employed by physicians in spine surgery has a Category I or III CPT code. When this is the case, an unlisted code might be used. It is incorrect to select an existing Category I code that resembles the procedure performed, or as an alternative to using an unlisted code to ensure payment. When reporting an unlisted code, the practice should obtain pre-authorization and also provide the payer with one or more comparable codes and set an appropriate fee based on the value of the comparable codes.
National recommendations
Some examples of national recommendations for reporting new, and not so new devices, are described below.
Posterior spinous process distraction device. Placement of an interspinous process distraction device is reported with a Category III code, which was developed in 2008. This device, which might also referred to as an interspinous process implant, is placed between the spinous processes to reduce compression in a lumbar interspace. The code, as shown below, includes bony removal necessary to place the device and any image guidance, according to CPT. The codes to report placement of this device are:
– 171T – Insertion of posterior spinous process distraction device, including necessary removal of bone or ligament for insertion and imaging guidance, lumbar; single level; and
– 0172T – Each additional level (list separately in addition to code for primary procedure).
Teri Romano
Posterior spinous process fixation device. A spinous process fixation device typically consists of a small interspinous plate or clamp attached to adjacent spinous processes to stabilize the segment by distraction and promote fusion while maintaining motion.
The fixation device is reported with an unlisted code (22899), not a Category I instrumentation code, such as 22840. Code 22840 is not appropriate since 22840 is specifically for non-segmental instrumentation with pedicle screw fixation across one interspace or facet screw fixation. Fusion (22612) and placement of a bone graft, if performed at the same operative session, may be separately reported.
Facet wedge or dowel fusion (intrafacet implant). Placement of a posterior intrafacet implant, such as a facet wedge or dowel, is reported with a Category III code. Dowels or allograft implants are placed (open or percutaneously) at the facet joints to treat chronic facet-oriented back pain.
Kim Pollock
Typically, two allograft dowels are used to fuse the facet joints at each spinal level. The Category III codes for this technology are:
– 0219T – Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level, cervical;
– 0220T for the thoracic level;
– 0221T for the lumbar level; and
– +0222T for each additional level, cervical, thoracic or lumbar.
All imaging is included in these codes. CPT guidelines prohibit reporting traditional fusion for the facet fusion (22600-22614), instrumentation (22840, 22851) or bone graft harvest codes (20930-20913).
Combined interbody biomechanical device and plate. The Category I description and intent of anterior instrumentation (22845-22847) requires that the anterior instrumentation, typically a plate, cross the interspace and be attached to a minimum of two vertebrae. “Low-profile” intervertebral devices with an attached or even unattached plate/buttress screws or a device that cannot provide independent stabilization may not be coded as two devices. Therefore, reporting both a biomechanical interbody device (22851) and a plate code (22845) is incorrect and over-coding. The correct code for these combination devices is only 22851 since the primary intent of the device is to fuse an interspace.
Future articles in Spine Coding Source will focus on spine coding and documentation.
For more information:
Teri Romano, RN, MBA, CPC, and Kim Pollock, RN, MBA, CPC, are consultants with KarenZupko & Associates Inc. and serve as faculty members of the American Association of Neurological Surgeons national coding and reimbursement courses. For more information, visit www.karenzupko.com.
Disclosures: Pollock and Romano have no relevant financial disclosures.