The Spine Movement - July 2012

Dr. Morgan Lorio, Chair of the ISASS Coding & Reimbursement Task Force tackles a few of the larger issues in spine ambulatory surgery.

Morgan Lorio, MD FACSASCs: A Piece of the Spine Puzzle - One Surgeon's Thoughts

Morgan Lorio, MD FACS, Chair
ISASS Coding & Reimbursement Task Force

Ambulatory Surgery Centers (ASCs) with a spine focus should develop visions designed to provide real improved outcomes if they are to succeed. Albert Einstein's quote "the significant problems we face today cannot be solved by the same level of thinking that created them" has been applied to just this challenge.(1) To this end an approach to provide expedient quality spinal services may require a Walmartized design with a McDonald's-like delivery system model. Insurance carriers and industry will as a consequence embrace same with heavy hands. Spine surgeons will, as a consequence, increasingly use MIS techniques and technologies that address a Spine ASC safe outpatient or 23 hour discharge requirements. Older technologies, therefore, cannot be the way of the future. ASC spine surgeon directorships and ownership (targeted by ObamaCare) must advocate (at multiple levels) for the patient as well as the surgeon.

Spine ASCs are becoming an increasingly popular approach providing interventional pain procedures, MIS decompressions with or without stabilization, and vertebral augmentation. Provider capacity growth, high outpatient margin response, technological innovation (and surgeon understanding), enhanced surgeon production, and supply availability are postulated factors responsible for growth in spine ASCs, paraphrasing the McKinsey Global Institute.(2) A local interview of Elizabeth Trivett, RN, Administrator for Renaissance Surgery Center in Bristol, TN, confirms that "Work Comp carriers appreciate ASC cost effectiveness and outcomes... specifically, a zero (0)% infection rate in spinal procedures (including fusion) since opening seven years ago.” Mrs. Trivett further reports that current drawbacks remain, including "variance in carrier recognition or acceptance."

Obviously, patient selection impacts or directs point of service--Spine ASC versus Inpatient Admission. Vertebral augmentation underscores selection as a recent review (from 2001-2008) demonstrates treated VCF level means range approximately 1.18 for ASC cases versus 1.3 for inpatient cases. Additionally, real time fluoroscopy CPT code 76012 has shown gradually increased percentage rates compared with CT guidance or CPT code 76013. A good quality fluoroscopic C arm that accommodates a larger working area has become a necessary workhorse at spine ASCs. Geographic variation for musculoskeletal procedures raises concerns for post procedural monitoring in the aging spine.(3) The increased costs (due to case complexity or aging spine issues) incurred for 23-hour observations within the spine ASC may be offset by baby boomer volume.

Just as there are geographic interstate variations in spine ASC utilization, there are interesting global differences in the "developing and developed worlds." Recently, the educational needs of neurosurgery trainees were polled with a 7-point Likert scale; Canadian (Toronto) neurosurgical residents reported that "they did not have enough ambulatory experience" as compared to Indonesian (Bandung) neurosurgical residents. Multifactorial challenges in the transition to outpatient spine care include resources, restricted resident work hours, medico-legal concerns, and balance within comprehensive accredited spine training program requirements.(4)

The growth in cost per case due to technology related change is unfortunately surpassing rising disease prevalence in the aging spine.(2) Emerging spine technologies, therefore, represent a double-edged sword wielded by the spine surgeon in the spine ASC. Spine ASC outcome measures will be mandated to establish minimum outcome standards if they are to more easily justify their existence to policy makers. Cost controls, meanwhile, will drive more patients to the efficient ASCs while hospitals will focus more on the true “in-patients.” Careful selection of patients will be crucial in the months and years ahead.


1. Weinstein, J, Brown, P, Hanscom, B, Walsh, T and Nelson, E "Designing an Ambulatory Clinical Practice for Outcomes Improvement: From Vision to Reality-The Spine Center at Dartmouth- Hitchcock, Year One." Quality Management in Health Care 8, no. 2 (2000): 1- 20.

2. Farrell, D, Jensen, E, Kocher, B, et al, "McKinsey Global Institute: Medicare Enrollment: National Trends 1966- 2007. Accounting For the Cost of US Health Care: A New Look At Why Americans Spend More." Washington, DC: McKinsey & Company, McKinsey Global Institute; 2008.

3. Gray, D, MD, Hollingworth, W, PhD, Onwudiwe, N, PharmD, Jarvik, J, MD, "Costs and Stat- Specific Rates of Thoracic and Lumbar Vertebroplasty, 2001- 2005." Spine vol. 33, no. 17 (2008 Lippincott Williams & Wilkins): 1905- 1912.

4. Bernstein, M, MD, Hamstra, S, PhD, Woodrow, S, MD, Goldsman, S, Reznick, R, MD, Fairholm, D, "Needs Assessment of Neurosurgery Trainees: A Survey Study of Two Large Training Programs in the Developing and Developed Worlds." Surgical Neurology 66 (2006): 117-126.

ISASS13 Call for Papers