Medicare Releases Proposed 2025 Inpatient Prospective Payment Rule: Important Changes Affecting Spine Surgery

April 17, 2024 – The Centers for Medicare and Medicaid Services (CMS) has released its 2025 proposed rule for the inpatient hospital setting. A number of changes are proposed with regard to spinal surgery, including the following:

• The ICD-10 Coding Committee released a new set of “diagnosis codes” created specifically to describe intervertebral disc degeneration with discogenic pain. These new codes will be finalized in June 2024 and will be effective for reporting by physicians, hospitals, and ASC’s October 1, 2024. The impact of these new ICD-10 diagnosis codes for discogenic low back pain, with or without leg pain, on spinal interventions and treatments is expected to be positive, allowing for more personalized and accessible care for patients with spinal disorders. Although these codes were released as part of this proposed rule, they are not open to public comment. These new codes are the direct result of many years of advocacy by our Society and our Reimbursement Task Force and surgeon advisors.
• CMS is proposing to create eight new MS-DRGs to delineate single versus multi-level lumbar fusion. The creation of these DRGs is anticipated to more appropriately track resource utilization by hospitals for the specific procedures and adjust hospital payment for the resources required for multiple-level fusions.
• Finally, CMS is proposing a new mandatory episode-based alternative payment model called TEAM (Transforming Episode Accountability Model), which is slated to be implemented January 1, 2026. Hospitals that are selected to participate will manage their total costs of care for spinal fusions (among other non-spine related procedures) and compare them to target CMS costs over a four-year period.

The ISASS Policy & Advocacy team are reviewing the proposed rule to identify any additional topics of interest to our members and will submit formal comments to CMS by June 10, 2024. Please reach out to Kim Norton, Policy & Advocacy Consultant, with any suggestions, questions, or concerns: knorton@isass.org

For more information, see the CMS Fact Sheet here.

And the rule itself here.