Fusion ICD Codes Changing?

The “devil in the details” of CMS (Centers for Medicare and Medicaid) reimbursement lies in the nomenclature of the ICD-9-CM procedure codes. Those codes are reported by hospitals to classify inpatient procedures. Then they’re combined with ICD-9-CM diagnosis codes to determine the DRG placement and subsequent payment to the hospital. When the codes get messed with, your reimbursements can change.

CMS is in the midst of considering revisions to, among others, codes for spine fusion procedures whose technologies have sprinted ahead of their current codes.

The last time CMS tackled significant code changes for spine procedures was four years ago when the agency developed codes for motion preservation procedures.

Kelli Hallas, Vice President of Reimbursement Services at Emerson Consultants, tells us that the agency has received several requests and recommendations to revise the current fusion codes to reflect the changing environment.

Categorized Forever?

When CMS developed the motion preservation codes, there was a lot of public and industry participation. According to Hallas, this time the changes are taking place without the participation of many smaller and mid-sized spine companies. At a September 16 CMS Coordination and Maintenance Meeting, Hallas says very few device manufacturers showed up and if they don't get involved, their products may end up being categorized in codes they don't like.

"It is imperative that companies review these proposed changes and determine the strategic impact (if any) to their business, " says Hallas.

If they get involved now, Hallas hopes that some of the smaller companies and newer technologies will be able to accurately provide information on their technology early on.

Fusion Alphabet Soup

“Pay attention to the terms included in the ‘Add inclusion term’ proposed revisions, ” said Hallas.

Those terms include DLIF, XLIF, AxiaLIF and others.

Go to PearlDiver spine analyst Matt Menze’s Web page  (http://www.pearldiverinc.com/pdi/spine.jsp) to see a U.S. Spine Fusion Summary 2006-2012 of volume of fusion procedures.

In a summary report of the September 16 meeting, CMS specifically cited support for the “EXtreme Lateral Interbody Fusion (XLIF) and Direct Lateral Interbody Fusion (DLIF) inclusion terms being proposed at code 81.06, Lumbar and lumbosacral fusion, anterior technique, versus code 81.08, Lumbar and lumbosacral fusion, posterior technique.”

The summary report also noted the comments from those who expressed their support of the proposed spinal fusion/refusion code title revision that would identify which column is being fused.

Andrew Cappucino, M.D., board certified in spinal surgery and orthopedic surgery, specifically stated that it is important to distinguish that the XLIF procedure uses a true anterior approach.

CMS staffer Mady Hue explained at the meeting that these same revisions would also apply to the spinal refusion codes. She also noted that this category of codes presented challenges, as both the approach and the technique concepts were historically included in this set of codes and no longer accurately apply in today’s environment.

Not everyone is in favor of the suggested changes. There are some who prefer a complete freeze on changing codes until a new and better way is devised to capture technology changes in new techniques.

Hallas says the proliferation of procedures and devices has caused confusion with providers who are not always sure which code most closely fits the procedure.

“Companies need to be sure they understand the payment implications from a change in the codes, ” added Hallas.

CMS is accepting comments to the proposal below until November 20, 2009. Comments should be sent to Mady Hue at CMS (Marilu.hue@cms.hhs.gov). 

Below were the changes presented at the September 16 ICD meeting: