ISASS Comments on 2018 Final OPPS & ASC Rule

What’s New in Spine Coding for 2018?
December 22, 2017
ISASS Policy & Advocacy News – January 2018
February 1, 2018
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On November 1, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System policy changes, quality provisions, and payment rates final rule. Please note that physician payment is made under the Physician Fee Schedule; hospitals are paid for outpatient services under the OPPS and ASCs are paid under the ASC payment system, both detailed in this rulemaking.

The ASC Payment Indicator for 63 CPT codes changed from J8 to G2 from the 2018 proposed rule to the 2018 final rule. ASC procedures assigned to J8 are designated as device-intensive, meaning the device cost exceeds 40 percent of the procedure’s mean cost. Device-intensive procedures are priced using a device-intensive payment methodology so that only the non-device (service) portion of the procedure is subject to the OPPS relative payment weight and uniform ASC conversion factor calculation. ASC procedures assigned to G2 are calculated solely based on the OPPS relative payment weight and the ASC conversion factor, without regard to any device costs.

Of the 63 codes impacted, the following spine codes changed from J8 to G2 from the 2018 proposed rule to the 2018 final rule:

CPT Code Descriptor Final 2017 Payment Indicator Final 2018 Payment Indicator Final 2017 Payment Rate Final 2018 Payment Rate Difference in Payment Rate from 2017 Final to 2018 Final
22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level J8 G2 $10,541.98 $7,539.67 -$3,002.31
22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level J8 G2 $10,541.98 $7,539.67 -$3,002.31
62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar J8 G2 $3,631.80 $2,721.78 -$910.02

ISASS submitted comments to CMS flagging the potential error and on December 22, the Centers for Medicare and Medicaid Services (CMS) issued a correction to the 2018 Final Hospital Outpatient and ASC rule. As part of the Correction Notice, CMS updated the payment indicators of several codes incorrectly assigned a G2 ASC payment indicator instead of a J8 (device-intensive) ASC payment indicator in the final 2018 rule. As part of the 2018 Correction Notice, CMS changed the ASC payment indicators for the following two surgical spine codes from G2 back to J8, thereby avoiding a decrease of more than $2,800.00 to ASCs for the procedures:

CPT Code Descriptor Final 2018 ASC Payment Indicator 2018 Correction Notice ASC Payment Indicator Final 2018 Payment Rate 2018 Correction Notice Payment Rate Difference in Payment Rate from 2018 Final to 2018 Correction Notice
22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level G2 J8 $7,539.67 $10,381.09 $2,841.42
22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level G2 J8 $7,539.67 $10,381.09 $2,841.42

However, CMS did not change the ASC payment indicator for the following surgical spine code back to J8 from G2, meaning CMS does not believe that the procedure meets its “clinical criteria” for device intensive status. This change in payment indicator results in a decrease of more than $900.00 to ASCs for endoscopic lumbar decompression from 2017 to 2018:

CPT Code Descriptor Final 2018 Payment Indicator 2018 Correction Notice Payment Indicator Final 2017 Payment Rate 2018

Correction Notice Payment Rate

Difference in Payment Rate from 2017 Final to 2018 Correction Notice
62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar G2 G2 $3,631.80 $2,721.37 -$910.43

According to CMS policy, procedures must meet the following criteria for device-intensive status:

  1. All procedures must involve implantable devices that would be reported if device insertion procedure were performed;
  2. the required devices must be surgically inserted or implanted devices that remain in the patient’s body after the conclusion of the procedure (at least temporarily); and
  3. the device offset amount must be significant, which is defined as exceeding 40 percent of the procedure’s mean cost.

Please note, these changes do not impact surgeon reimbursements under the Physician Fee Schedule. Click here for an updated comparison of OPPS and ASC reimbursements from 2017 to 2018.