ISASS supports decision making at the physician-patient level based on medical necessity and achieving the best outcomes to address the patient’s medical condition. Medical necessity should not be determined by a mere administrative code reporting system such as CPT. Prior to the July 1st implementation of CPT category III code 0334T, surgeons reported and were reimbursed for ALL sacroiliac joint fusion procedures when medically necessary, including minimally invasive, through the use of CPT code 27280.
To determine procedural approach prevalence associated with CPT code 27280, ISASS and the Society of Minimally Invasive Spine Surgeons conducted a survey of surgeons, and found that in 2012, nearly 90 percent of all SIJ fusions were performed using a minimally invasive approach. Yet despite the evidence that the MIS approach is by far the predominant approach, and has since 2011 become the standard of care for a select subset of patients, surgeons are now required to report a temporary, category III code (0334T) to describe their work. We cannot think of any other situation in which the standard of care for a given treatment has moved from a category I code to a category III code after being performed for four years with no discussion of coding appropriateness; we believe that payers, including Medicare, should continue to cover and pay for this procedure regardless of the coding change.
The CPT Editorial Panel states that “it is not reasonable to categorically deny payment for CPT Category III codes since they are effectively more specific, more functional versions of unlisted codes which many payers cover with appropriate documentation.” Additionally, the Panel says, “the assignment of a CPT Category III code to a service does not indicate that it is experimental or of limited utility, but only that the service or technology is new and is being tracked for data collection.”
While physicians are now required to adhere to an administrative coding change and report MIS SIJ fusions with a new category III code, the procedure has not changed, nor has the patient, the condition being treated, or the clinical resources associated with the procedure. ISASS believes that payers should make coverage decisions for a given procedure based on the clinical decision of the physician and the medical necessity presented by the patient, and NOT based on the CPT code required to report the work.