The Spine Movement - June 2012
Dr. Morgan Lorio, Chair of the ISASS Coding & Reimbursement Task Force, gives a look at concrete examples of the increasingly difficult environment for spinal procedures.
Coding Challenges Loom Large in 2012
Morgan Lorio, MD FACS, Chair
ISASS Coding & Reimbursement Task Force
Coding changes that bundle spine services and ultimately reduce physician reimbursement, as cited in the accompanying article by Dr. Choll Kim, are indeed something of grave concern to spine surgeons. Yet the impact of these bundled codes for spinal procedures in 2012 has not been fully felt or even recognized by those who provide spine care. For many payers, there is an approximate six-month delay between date of service and accounts received, and an even longer timeframe for other carriers that follow Medicare’s lead; a comprehensive review will ultimately show a significant global impact on spine-care services. What follows are concrete examples of the increasingly difficult environment for spinal procedures, including minimalist to maximal exposure spine procedures in 2012.
A growing number of spine surgeons have moved interventional spine injections in-house. A looming issue, therefore, is the bundling of fluoroscopic use for interventional spine injection procedures (diagnostic and/or therapeutic). Fluoro is now bundled into: facet joint injection, CPT codes 64490-64495; transforaminal epidural injection 64479, 80 and 64483, 84; facet joint destruction 64633-64636; and sacro-iliac injection 27096. The costs of a fluoroscopic C-arm run on the average of $100K-250K. Furthermore, these devices typically require $1,000 monthly maintenance service contracts. The use of spinal catheters – which costs on average $100 – to navigate and provide targeted medication delivery to patients suffering from stenosis, etc., has additionally been bundled into the epidural codes.
Spine surgeons (and interventionalists) may reconsider where or when they might provide these patient-convenient, in-house services. This is analogous to hiring a painter to paint your house, and then telling him (after you’ve negotiated a price) that he has to foot the cost of the paint! I am reminded that just several years ago, it was decided that if select injections weren't done without fluoroscopy then they would only be paid as trigger point injections; now that injection precision has been raised to a higher standard, compliance has been rewarded with diminished reimbursement.
For the aging, degenerative spine or failed-back surgery, drastic salvage typically requires hardware removal. This hardware removal is now bundled into the reimbursement for the subsequent procedure, yet it still requires a lot of extra work. (Returning to the home maintenance analogy, it is understood that the cost of home remodeling reflects the added labor required to tear down and remove the existing structure before the remodeling is undertaken.) In the past this arduous work of hardware removal had a specific relative value or RVU. Now CPT codes 22850 and 22852 are no longer considered when re-instrumentation (22840 and 22842) is performed, even at a different level; in effect costing the surgeon 5- 10 WRVUs. However, take note: our adult orthopedic reconstructive colleagues continue to receive additional value for knee and hip revision surgeries. One recent meta-analysis by Polly et al suggests that there is sufficient outcome data confirming SF-36 value in surgically addressing the degenerative spine, and that the spine outcomes parallel knee and hip arthroplasty outcomes which, coincidentally, require revision strategies inclusive of additional reimbursement. We as revision spine surgeons are asked to accept this "equitable" transaction while braving the deleterious effects of ionizing radiation (fluoro CPT code 76000-26), which has similarly been bundled into most of the 2012 spine surgery codes.
We as targeted spine surgeons have not received a proper rationale as to why or how these changes reflect an equitable transaction for specialty spine services rendered; yet, if we continue in our calling, then each of us embodies an Atlas, supporting the backbone of America while ultimately undervalued. Appreciating the relative value of newer technologies and procedures will become increasingly difficult for a healthcare system that undervalues its tried and true older technologies and procedures.