CMS Announces Revision to New Payment Edits for Spine Surgery

The July 1, 2023, the National Correct Coding Initiative Procedure-to-Procedure (PTP) edit file for Medicare claims includes Column 1 codes 22630, 22632, 22633, and 22634 with Column 2 codes 63052 and 63053 with Correct Coding Modifier Indicator (CCMI) of 1. This means that CMS will deny 63052 and 63053 when billed with 22630, 22632, 22633, or 22634 unless an appropriate payment modifier such as 59 is included.

Upon receiving notice of the edits, ISASS immediately worked with other stakeholders to reach out to CMS to contest the edits. 63052 and 63053 are add-on codes for decompression when done with a PLIF/TLIF and should not be subject to denial when billed with the parent codes. CMS had previously attempted a similar edit in 2021 and ISASS and other stakeholders succeeded in reversing that attempt.

In response to the rapid response, CMS quickly announced plans to delete these edits retroactive to their implementation date of July 1, 2023. CMS implements changes to edits as soon as technically possible. CMS stated they expect to implement this change in the January 1, 2024 edit files. Changes to edits are not final until publicly released by CMS at a future date.

These PTP edits have a CCMI of 1 which indicates that they allow the use of an NCCI PTP-associated modifier to bypass the edit. Until CMS implements the change, a provider may use any NCCI PTP-associated modifier if they believe that the requirements for use of that modifier are met, as outlined in CMS NCCI guidance.

If ISASS members have any questions regarding the edit and the forthcoming retroactive reimbursements, please contact Matthew Twetten at matthewtwetten@gmail.com.