The Spine Movement - June 2012
Dr. Choll Kim examines the ever trickier coding landscape as it relates to Minimally Invasive Surgery.
Important Changes to the CPT Coding of Minimally Invasive Surgery
Choll Kim, MD, PhD
Spine Institute of San Diego
Center for Minimally Invasive Spine Surgery
The passing of 2011 was met with important changes to the CPT coding landscape as it relates to minimally invasive surgery. The first coding change was for minimally invasive posterior lumbar interbody fusions. Although the coding scenario is similar whether it is performed with traditional open techniques, or minimally invasively, the impact on MIS is significant as MIS TLIF remains one of key minimally invasive reconstruction strategies used by MIS surgeons.
The change in 2012 bundles codes for the posterior interbody fusion (22630 and 22634 for additional levels) and the posterolateral fusion (22612, 22614 additional levels) into a single posterior interbody fusion code (22633, 22634 additional levels). The impact of such a change can be significant. A coding scenario for a 1 level MIS TLIF using the Anthem Blue Cross fee schedule shows a decrease in payment of 13.4% for the fusion portion of the procedure. For the entire procedure, which typically includes posterior instrumentation, the difference still amounts to an 8.7% overall decrease in payment. For 2-level procedures, the fusion payment is decreased by 17.1% and the overall procedure by 11.1%. Such changes may have a significant impact on practices that specialize in minimally invasive surgery since a key tenet of MIS is to avoid midline laminectomies and wide posterolateral fusions. The CPT coding change has not yet been adopted by all carriers, but such changes that decrease physician payments will undoubtedly be difficult to avoid.
The second coding change that specifically affects MIS surgery is related to the treatment of herniated discs. This remains the most common problem treated with spinal surgery. The code 63030 is described in CPT 2012 as “Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar.” Previous language included the term “(including open or endoscopically-assisted approach).” The CPT 2012 language allows for use of the operating microscope to “directly visualize” the surgical target site. When an endoscope is used, CPT instructional notes now state that Category III codes be used. Code 0275T is to be used for a “percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar.” Many surgeons believe this language is intended for a new procedure called “MILD” which is a percutaenous, flouroscopically guided method to debride the ligamentum flavum (typically for the treatment of spinal stenosis). It is not clear from this language if this encompasses an emerging minimally invasive treatment for herniated disc using a transforaminal, endoscopic approach. This approach is not intralaminar, but rather transforaminal. Furthermore, it is not clear if this entails a relatively well-established procedure called “MED”, or micro-endoscopic diskectomy, where a tubular retractor and overhanging endoscope is used to assist in the visualization of the surgical target site.
Such changes in CPT coding threatens to slow the rate of key advancements in spinal surgery, especially as it relates to minimally invasive surgery. It is imperative that modifications to the CPT codes are pursued with diligence and caution. The burden remains on the community of surgeons to clarify the subtle distinctions that differentiate modifications of existing technologies that improve patient care from novel technologies that may pose undue risk and uncertainty.