Anthem Blue Cross and Blue Shield Central Region Clinical Claim Edit

Transcription

1 Subject: Laminotomy (Hemilaminectomy) with Decompression of Nerve Root(s), Including Partial Facetectomy, Foraminotomy and/or Excision of Herniated Intervertebral Disc, Reexploration, Single Interspace-Lumbar with Arthrodesis, Posterior Interbody Technique, Including Laminectomy and/or Discectomy to Prepare Interspace (Other than for Decompression, Single Interspace-Lumbar or Discectomy, Anterior, with Decompression of Spinal Cord and/or Nerve Root(s) with Arthrodesis, Anterior Interbody Technique, Including Minimal Discectomy to Prepare Interspace: Cervical Edit# 577 Effective: 08/17/ /31/2013 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Description CODE RULE CODE Separate Reimbursement Separate Reimbursement LT Separate Reimbursement RT Separate Reimbursement Incidental Separate Reimbursement Rationale Anthem Central Region does not bundle with 22630, does not bundle with 22630, does not bundle LT with and does not bundle RT with Based on the Complete Global Service Data for Orthopaedic Surgery, CPT Code 22630, code is not listed as a service that is included when performing Based on the National Correct Coding Initiative Edits, code is not listed as a component code to code Therefore, if is submitted with both services reimburse separately, if is submitted with both services reimburse separately, if LT is submitted with both reimburse separately and if RT is submitted with both services reimburse separately. Anthem Central Region bundles and as incidental with Based on the Complete Global Service Data for Orthopaedic Surgery, CPT code 22630, code is listed as a service that is included when performing Based on the National Correct Coding Initiative Edits, code is listed as a component code to code Since is an add on code that only may be reported along with 63047, follows the same rationale that is used with Therefore, if and Central Region Claim Edit#577 Page 1 of 5

2 are submitted with only reimburses Anthem Central Region does not bundle with Based on CPT Assistant article: To report code 22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); cervical below C2, in addition to code , Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace, the surgeon must have performed additional procedure(s) and work that leads to the decompression of neural elements. In most cases, the dura and/or neural elements are exposed to ensure decompression which, for reporting purposes, is considered over and above the work described by code Therefore, in this instance, the decompression procedure (with the modifier -51 appended) would be reported in addition to code Examples of types of additional procedures include drilling off the posterior osteophytes using the operating microscope, opening the posterior longitudinal ligament to look for free disk fragments (decompressing the spinal cord), or removing far lateral disk fragments to decompress the nerve roots. Based on the Complete Global Service Data for Orthopaedic Surgeons, code is listed as a service that is not included when performing CPT code or add-on code Based on the National Correct Coding Initiative Edits, code is not listed as a component code to code Since is an add-on code that is to be used along with the rationale for is the same as the rationale used for Therefore, if is submitted with both services reimburse separately and if and are submitted with all services reimburse separately. Reference 1.American Academy of Orthopaedic Surgeons. CPT Code: Complete Global Service Data for Orthopaedic Surgery. 2007: pg American Academy of Orthopaedic Surgeons. CPT code Complete Global Service Data for Orthopaedic Surgery. 2007: page Centers for Medicare and Medicaid (July 1, 2007-September 30, 2007) National Correct Coding Initiative Edits-Version Retrieved July 5, 2007 from the World Wide Web: ilterbydid=- 99&sortByDID=2&sortOrder=ascending&itemID=CMS046542&intNumPerPage=10 4. American Medical Association. Coding Consultation-Nervous System, 63040, 63042, (Q&A). CPT Assistant, 1999: 9(1): 12 Central Region Claim Edit#577 Page 2 of 5

3 Subject: Laminotomy (Hemilaminectomy) with Decompression of Nerve Root(s), Including Partial Facetectomy, Foraminotomy and/or Excision of Herniated Intervertebral Disc, Reexploration, Single Interspace-Lumbar with Arthrodesis, Posterior Interbody Technique, Including Laminectomy and/or Discectomy to Prepare Interspace (Other than for Decompression, Single Interspace-Lumbar or Discectomy, Anterior, with Decompression of Spinal Cord and/or Nerve Root(s) with Arthrodesis, Anterior Interbody Technique, Including Minimal Discectomy to Prepare Interspace: Cervical Edit# 577 Effective: 05/25/ /16/2007 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Description CODE RULE CODE Incidental Separate Reimbursement Incidental Separate Reimbursement Incidental Separate Reimbursement Rationale Anthem Central Region bundles with 22630, does not bundle with Based on CPT Assistant article: Coding Consultation, Musculoskeletal System, Surgery, 22554, 22630, , (Q&A): Question The descriptors of codes and describe anterior (22554) or posterior (22630) interbody technique arthrodeses to include laminectomy, and/or discectomy to prepare the interspace (other than for decompression). In what procedural circumstance would the code(s) be reported in addition to code 22630? Similarly, in what procedural circumstance would code(s) be reported in addition to code 22554? AMA Comment For both codes and 22630, if the surgeon is removing disk and/or bony endplate solely with the need to prepare the vertebrae for fusion; then no additional series code(s) is Central Region Claim Edit#577 Page 3 of 5

4 reported. The appropriate , code(s) should be reported, when in addition to removing the disk and preparing the vertebral endplate, the surgeon removes posterior osteophytes and decompresses the spinal cord or nerve root(s), which requires work in excess of that normally performed when doing a posterior lumbar interbody fusion (PLIF). Based on a second CPT Assistant article, Coding Consultation, Nervous System, 63040, 63042, (Q&A) Question My physician performs reexploration of L4-5, and then goes up or down a level to perform a laminectomy at a new level that has not been operated on in the past. What are the appropriate codes for this procedure? AMA Comment From a CPT coding perspective, it is appropriate to report CPT code to describe the procedure where a laminotomy is performed while concurrently performing nerve root decompression, partial facetectomy, foraminotomy, and/or excision of herniated intervertebral disk with reexploration at the lumbar level. CPT code and subsequent indented code 63042are the only codes which may be reported for procedures performed on a recurrent herniated nucleus pulposus. If a laminectomy, facetectomy, and foraminotomy are performed concurrently, unilaterally or bilaterally, with decompression of the spinal cord, cauda equina and/or nerve roots, on a single vertebral segment (not interspace) at the lumbar level, and this segment has not been previously explored, then it would be appropriate to report CPT code CPT code is an add-on code which may be reported only when has been reported for the first lumbar vertebral segment procedure, and it is necessary to report procedures for one or more additional segments is a code that is not listed as an appropriate procedure ( , ) that would normally be submitted with Based on another CPT Article & are for recurrent herniated nucleus pulposus. If and are being performed for a recurrent herniated pulposus, append modifier 59 to and Therefore, if is submitted with only reimburses, but if and is submitted with all services reimburse separately. Anthem Central Region bundles and as incidental with Based on CPT Assistant article, listed above, and is for the lumbar area are not appropriate to submit if the surgeon is removing disk and/or bony endplate solely with the need to prepare the vertebrae for fusion. Therefore, if and is submitted with only reimburse. Anthem Central Region does not bundle and with Based on CPT Assistant article, listed above, if and was being performed to remove posterior osteophytes and decompression of the spinal cord or nerve root(s), then append modifier 59 to and and both and and reimburse separately. Anthem Central Region bundles and as incidental with Based on CPT Assistant Central Region Claim Edit#577 Page 4 of 5

5 Reference article listed above, For both codes and 22630, if the surgeon is removing disk and/or bony endplates solely with the need to prepare the vertebrae for fusion; then no additional series code(s) is reported Therefore, if and is submitted with only reimburses. Anthem Central Region does not bundle and with Based on CPT Assistant article: To report code 22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); cervical below C2, in addition to code , Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace, the surgeon must have performed additional procedure(s) and work that leads to the decompression of neural elements. In most cases, the dura and/or neural elements are exposed to ensure decompression which, for reporting purposes, is considered over and above the work described by code Therefore, in this instance, the decompression procedure (with the modifier -51 appended) would be reported in addition to code Examples of types of additional procedures include drilling off the posterior osteophytes using the operating microscope, opening the posterior longitudinal ligament to look for free disk fragments (decompressing the spinal cord), or removing far lateral disk fragments to decompress the nerve roots. 1. American Medical Association. Coding Consultation-Musculoskeletal System, Surgery, 22554, 22630, , (Q&A). CPT Assistant, 2001; 1(12): American Medical Association. Coding Consultation-Nervous System, 63040, 63042, (Q&A). CPT Assistant, 1999; 9(1): 12 Claim Edit History 01/01/2014 Archived: Following NCCI 08/16/2007 Edited 05/25/2007 Adopted Central Region Claim Edit#577 Page 5 of 5