CPT code and description
63047 – Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar – average fee amount – $1100 – $1200
63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar) average fee payment – $1110 – $1130
63045 – LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT CERVICAL
63046 – LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT THORACIC
63048 – LAM FACETECTOMY&FORAMTOMY 1 SGM EA CRV THRC/LMBR
Note: Codes 63030 and 63047 are bundled per the NCCI edits with code 22630. CPT® Assistant (January 2001, page 12) states that these codes can be reported in addition to the fusion code if performed for decompression (apply modifier-59 to the decompression code in this instance.)
What is the most appropriate way for a physician, hospital, ambulatory surgical center or other health care professional to report to Oxford for bilateral eligible spinal codes such as code 63035, Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure), if the procedure is performed on multiple levels of the same spinal region?
If the laminotomy is performed bilaterally, report code 63020 or 63030 with modifier 50 for the first interspace. If a laminotomy of a second interspace is performed bilaterally, use add-on codes to represent additional levels rather than sides. In this instance, report code 63035 with modifier 50. If a laminotomy of additional interspaces (3 or more) is performed bilaterally, report code 63035 with modifiers 50 and 59 or XS with the appropriate number of units.
Medicare CCI Policy to Bundle Decompression with Fusion
As we advised many of you earlier this year, Medicare revised the National Correct Coding Initiative (CCI) Policy Manual, Chapter 4, Section H, Paragraph 25 for 2015 to add a new policy to bundle Redo and Lateral Recess Laminectomies (CPT 63042, 63044, 63047, and 63048) with posterolateral interbody fusions (CPT 22630, 22632, 22633, and 22634). This change was effective 1 Jan 2015 and we had a couple of reports from customers that their decompressions have been denied after the first of the year by their carriers even though the customer billed the decompression procedure code with modifier 59. Customers are urged to monitor their remittance notices to see how their carrier is implementing this policy.
The new policy statement is:
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.
Financial Impact of this change
This policy change effectively cuts the typical Medicare reimbursement for a single level lumbar interbody fusion procedure by 15%. A review of lumbar interbody fusion cases coded by INCISIVE MD users indicates that more than 90% of the time, decompression laminectomy is reported with lumbar interbody fusion; typically CPT 22633 with 63047.
PLIF and TLIF Procedures
For 2012, the AMA made changes to the Lumbar and Thoracic codes for Posterior Fusion procedures by combining commonly performed procedures into one code.
The 22610 code for an Arthrodesis (Fusion) using the Posterior or Posterolateral Technique, single level; Thoracic now states this code is done WITH the Lateral Transverse Technique (the code previously stated with or without).
Code 22612 for an Arthrodesis, posterior or posterolateral technique, single level; Lumbar now states this code is done WITH the Lateral Transverse Technique (the code previously stated with or without). This code has an instructional note to NOT report the 22612 code with code 22630 for an Arthrodesis, Posterior Interbody Technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar. The codes can only be billed together when the procedures are performed at different spinal levels or alone.
The new CPT code for use instead for the PLIF Posterior Lumbar Interbody Fusion procedure for 2012 would now be 22633 for an 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 and segment;
Lumbar. Use new Add-on Code 22634 for additional Lumbar levels performed.
In these procedures, the surgeon removes the entire facet joint so that more disc material can be excised during the procedure and producing less nerve retraction. These procedures are only performed on one side of the spine – not bilaterally, which would result in spinal instability.
An Example of coding for the PLIF procedure performed at 2 levels L3-4 and L4-5 using cages and a morcellized autograft harvested from the iliac crest would be:
Anthem Central Region does not bundle 63042 with 22630, does not bundle 63042-50 with 22630, does not bundle 63042-LT with 22630 and does not bundle 63047-RT with 22630. Based on the Complete Global Service Data for Orthopaedic Surgery, CPT Code 22630, code 63042 is not listed as a service that is included when performing 22630. Based on the National Correct Coding Initiative Edits, code 63042 is not listed as a component code to code 22630. Therefore, if 63042 is submitted with 22630—both services reimburse separately, if 63042-50 is submitted with 22630—both services reimburse separately, if 63042-LT is submitted with 22630—both reimburse separately and if 63042-RT is submitted with 22630—both services reimburse separately.
Anthem Central Region bundles 63047 and 63048+ as incidental with 22630. Based on the Complete Global Service Data for Orthopaedic Surgery, CPT code 22630, code 63047 is listed as a service that is included when performing 22630. Based on the National Correct Coding Initiative Edits, code 63047 is listed as a component code to code 22630. Since 63048 is an add on code that only may be reported along with 63047, 63048 follows the same rationale that is used with 63047. Therefore, if 63047 and 63048+ are submitted with 22630—only 22630 reimburses
Anthem Central Region does not bundle 63020 with 63043+. Based on the Complete Global Service Data for Orthopaedic Surgery manual, code 63020 is not listed as a service that is included or not included in the global service of CPT Code: 63043. Based on the National Correct Coding Initiative Edits, code 63020 is not listed as a component code to code 63043. Therefore, if 63020 is submitted with 63043—both reimburse separately.
Anthem Central Region does not bundle 63030 with 63044+. Based on the Complete Global Service Data for Orthopaedic Surgery manual, code 63030 is not listed as a service that is included or not included in the global Service of CPT Code: 63044. Based on the National Correct Coding Initiative Edits, code 63030 is not listed as a component code to code 63044. Therefore, if 63030 is submitted with 63044—both reimburse separately.
Anthem Central Region does not bundle 63035+ with 63043 or 63044. Based on the Complete Global Service Data for Orthopaedic Surgery manual, code 63035 is not listed as a service that is included or not included in the global service of CPT Codes: 63043 or 63044. Based on the National Correct Coding Initiative Edits, code 63035 is not listed as a component code to code 63043. Based on the 2004 CPT manual code 63035+ is an add on code and is to be used in conjunction with codes 63020 and 63030. If 63020 and 63030 are appropriate for submission with 63043 and 63044—then code 63035 follows the same guidelines as listed in the CPT manual for codes 63020 and 63030. Therefore, if 63035 is submitted with 63043 or 63044—both services reimburse separately
CPT 63047 ($36,423.00 billed, paid at $9,430.06) defined as “Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar” (L3)
“I am in review of the operative report. The billing should be as follows-It can be either 63047 (L3-4) and 63048 (L4-5 and L5-S1) OR 63030-59, 63035-59, 63047 for discectomy levels and above level. Cannot bill both at the same level/interspace. Either of these two options are billed with 22612-51, 22614 times 2, 20936, 20937, 38229 and 69990. These are based according to the American Association of Neurosurgical Guidelines.”
As to CPT 63030, claimant supplies NCCI materials that support the primary code CPT 63047 (highest value procedure) in column 1 lists CPT 63030 in column 2 with an inidcator of “1” and thus, requiring a modifier. This would be the same for CPT 63048 and the corresponding additioanl level of 63035. Modifier-59 was billed with both codes to support the billing of both codes. Claimant notes that the medical circumsatnces of the patient warranted the billing of both codes in this patient. The surgon testified as to the basis for the separate billing.
Normally, the surgeon would not be requried to bill all codes billid in this case, but the patient had numoerous disc abnormalities requiring distinct procedures. CPT 63030 and 63035 address disc “interspace” and hence only 2 units were billed for the L4-5 and L5- S1inter body discectomy with reomval of the disc. 63047 and 63048 address single vertebral segments and hence L3, L4, L5 and S1 are billed separately to encompass the laminectomy and formainotomy. The patient had disc herniations requiring actual discetomites with disc removal to be perfomed in addition to the stenosis. As the patient presented with stenosis in addition to the herniated discs, 63047 and 63048 were justifed (as is addressed in the definitions for these codes).
It is noted that Dr. does not provide actual billing guidelines and did not have the actual billing showing that a modifier was used. In this case, I find that Dr. X explanation is compelling and is supported by the separate diagnoses and the NCCI note an indicator of “1” meaing that there are clincal circumstances that would allow for separate billing or non-inclusion.
As to CPT 63030, 63035, 63047, 63048, 22612 and 22614 the provider bills in excess of what several other providers bill and was often paid less than the billed rate. Ingenix, however, would support a much higher rate of reimbursement than paid by respondent and supports many of the charges of the claimant in this case. As noted, multiple databases can be utilized to support charges billed and/or paid. The database used by respondent is not in evidence and the disparity as between Wasserman and Ingenix is noted. In this case, based on my review of all the evidence, I find $25,000 is an appropriate UCR for CPT 63030; $8,000 for CPT 63035; $29,000 for CPT 63047; $8,300 x 3 for CPT 63048; $26,000 for CPT 22612 and $8,000 for CPT 22614 x 2. As noted, CPT 63030-59 and 22612 are reduced by 50% per the MPRF.