News and noteworthy information for January 2017:
- A Closer Look at Biomechanical Device Coding
- MACRA/QPP Survey
- Global Surgery Data Collection Program Finalized
- Judge Blocks Aetna-Humana Merger
- Price Testifies at Senate Confirmation Hearings
- ICD-10 Code Updates and Impact to PQRS
- FDA Reclassifies Pedicle Screw Systems
A Closer Look at Biomechanical Device Coding
Effective January 1, 2017, CPT® code 22851was deleted from the CPT code set and replaced by three new codes to report insertion of biomechanical devices:
CPT Code 22853 – Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)
CPT Code 22854 – Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
CPT Code 22859 – Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
These three new codes are a result of the Centers for Medicare and Medicaid Services (CMS) flagging CPT code 22851 on its list of high expenditure procedure codes not reviewed in at least 6 years. The Relative Value Scale Update Committee (RUC) recommended review of the code because of the frequency of use, historical consistent growth of utilization and the fact that the code had not been surveyed since April 1995. The CPT Editorial Panel approved deletion of CPT code 22851 and creation of CPT codes 22853, 22854 and 22859 to report biomechanical device insertion at the October 2015 CPT meeting.
This new family of codes is reported per level and was designed so that each code captures insertion of both devices with integral anterior instrumentation for device anchoring and devices without integral anterior instrumentation for device anchoring, regardless of approach. The difference in the codes lies in the location of the device insertion (i.e. the intervertebral disc space or the vertebral body defect) and whether interbody arthrodesis is being performed: 22853 for disc space defect with fusion, 22854 for vertebral body defect with fusion, and 22859 for disc space or vertebral body defect without fusion.
Because each code can be used to report insertion of devices with integral anterior instrumentation for device anchoring and devices without integral anterior instrumentation for device anchoring, there are cases in which the surgeon inserts a device without integral instrumentation for device anchoring and should appropriately report separate anterior instrumentation, when placed, using CPT codes 22845, 22846 or 22847 in addition to the appropriate biomechanical device code and the primary procedure code. In cases where the surgeon inserts a device with integral instrumentation for device anchoring (i.e. fixation that cannot be independently implanted), CPT codes 22845, 22846 and 22847 should not be reported.
On December 13, 2016, ISASS was informed by CMS and the National Correct Coding Initiative (NCCI) that CMS will finalize and implement coding edits effective April 1, 2017 to bundle anterior instrumentation codes 22845, 22846 and 22847 when reported with 22853 and 22854. This means that Medicare will not reimburse surgeons for 22845, 22846 or 22847 when reported in conjunction with 22853 or 22854, even when the codes are used appropriately to report separate anterior instrumentation to anchor a cage without integral instrumentation. CMS will only allow use of modifiers to bypass the edits if the surgeon performs additional anterior instrumentation unrelated to anchoring the device. ISASS maintains that CMS and NCCI are misinterpreting the descriptors of these new codes and has launched a multi-society effort to dispute these edits. In response to our outreach, CMS retracted its plans to implement coding edits to bundle 22845, 22846 and 22847 with 22859, however we will continue to fight for appropriate coding and reimbursement for 22853 and 22854 with the anterior instrumentation codes.
All CPT code descriptors have been taken from Current Procedural Terminology (CPT®) 2017, American Medical Association. All Rights Reserved. CPT is registered trademark of the American Medical Association.
The coding opinions referenced are those of the ISASS Coding & Reimbursement Task Force based on their coding experience and do not constitute legal advice. Every effort is made to ensure the accuracy of information provided, however, these opinions do not replace information contained in public or private payer policies or any published CPT material. The final decision for coding any procedure must be made by the surgeon, considering regulations of insurance carriers and any local, state or federal laws that apply to the surgeon’s practice. ISASS nor any of its officers, directors, agents, employees, committee members or other representatives shall have any responsibility or liability for any claim, including but not limited to any claims for costs, legal fees, Medicare or insurance fraud, arising from the use of these opinions.
The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) was bipartisan legislation signed into law in April 2015 to permanently repeal the Sustainable Growth Rate (SGR), streamline physician quality reporting programs, and provide incentive payments for physician participation in alternative payment models. MACRA sunsets the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier, and the Medicare Electronic Health Record (EHR) Incentive Program and establishes an umbrella Quality Payment Program (QPP) with two new pathways for payment: 1. Merit-Based Incentive Payment System (MIPS) and 2. Advanced Alternative Payment Models (Advanced APMs). The Centers for Medicare and Medicaid Services (CMS) recently issued a final rule to begin implementing the program effective January 1, 2017. A full summary of the final rule is available here. The Centers for Medicare and Medicaid Services (CMS) will host a webinar for small, rural and underserved practices on Wednesday, February 1 from 1:00 p.m. to 2:15 p.m. ET to learn more about participation in MIPS. You or your staff can register for the webinar here.
If you haven’t already, please take this very brief, five-question ISASS survey to help us better prepare you to successfully participate in the program.
Global Surgery Data Collection Program Finalized
Many surgical spine procedures are valued and paid for as part of global packages that include the procedure and the services typically furnished in the periods immediately before and after the procedure. Citing concerns with lack of data to verify and update the values of codes with global packages, in the 2017 proposed Physician Fee Schedule rule, the Centers for Medicare and Medicaid Services (CMS) proposed an extremely burdensome data collection strategy to gather information on the frequency of, and inputs involved in furnishing global services, including the procedure, pre-operative visits, post-operative visits, and other services for which payment is included in the global surgical payment for 4,200 codes with a 10- or 90-day global period.
After receiving substantial pushback from the physician community and medical societies including ISASS, in the 2017 final rule, CMS finalized a data collection strategy that significantly reduces the burden on surgeons and their practices compared to the proposed rule. The final program requires surgeons in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island to report on claims data on post-operative visits furnished during the global period of specified procedures using CPT code 99024, beginning July 1, 2017. The specified procedures are those that are furnished by more than 100 practitioners and either are nationally furnished more than 10,000 times annually or have more than $10 million in annual allowed charges. The complete list of procedures can be accessed here and includes the following spine procedures:
- CPT Code 22513 – Perq vertebral augmentation
- CPT Code 22514 – Perq vertebral augmentation
- CPT Code 22551 – Neck spine fuse&remov bel c2
- CPT Code 22558 – Lumbar spine fusion
- CPT Code 22600 – Neck spine fusion
- CPT Code 22612 – Lumbar spine fusion
- CPT Code 22630 – Lumbar spine fusion
- CPT Code 22633 – Lumbar spine fusion combined
- CPT Code 22830 – Exploration of spinal fusion
- CPT Code 63030 – Low back disk surgery
- CPT Code 63042 – Laminotomy single lumbar
- CPT Code 63045 – Remove spine lamina 1 crvl
- CPT Code 63047 – Remove spine lamina 1 lmbr
- CPT Code 63056 – Decompress spinal cord lmbr
- CPT Code 63081 – Remove vert body dcmprn crvl
- CPT Code 63650 – Implant neuroelectrodes
- CPT Code 63685 – Insrt/redo spine n generator
Surgeons who practice in practices with fewer than 10 practitioners are exempted from required reporting, but are encouraged to report if feasible. Although reporting is required for global procedures furnished on or after July 1, 2017, CMS encourages all practitioners to begin reporting as soon as possible. CMS will host a National Provider Call on Tuesday, April 25 from 1:30 p.m. – 3:00 p.m. ET to provide more information and answer questions on the program.
Judge Blocks Aetna-Humana Merger
On January 23, U.S. District Judge John D. Bates issued a ruling to block the proposed Aetna-Humana merger. The judge found that the merger would have substantially lessened competition in Medicare Advantage and commercial health insurance markets. The ruling acknowledges that meaningful action was needed to preserve competition and protect high-quality medical care from unprecedented market power that Aetna would acquire from the merger deal. The court’s ruling sets a notable legal precedent by recognizing Medicare Advantage as a separate and distinct market that does not compete with traditional Medicare. This was a view advocated by the American Medical Association and other medical specialty societies, as well as leading economists. The ruling is seen as a landmark win for organized medicine.
Price Testifies at Senate Confirmation Hearings
President Trump’s appointee to Secretary of the U.S. Department of Health and Human Services (HHS), Congressman Tom Price, MD (R-Ga.), testified at confirmation hearings before the Senate Committee on Health, Education, Labor and Pensions (HELP Committee) on January 18 and before the Senate Finance Committee on January 24. Price faced questions from both committees on his background and qualifications, past policy stances, ethics related to stock trades and how the health care system will be reformed under the Trump Administration. Price also faced questions related to President Trump’s executive order aimed at minimizing the economic burden of the Patient Protection and Affordable Care Act pending repeal.
Price is an orthopaedic surgeon from Georgia where he spent 20+ years treating patients in the metro-Atlanta area. He was elected to four terms in the Georgia State Senate before being elected to Congress in 2004. He served on the House Committee on Ways and Means, including the Subcommittee on Health, and served as the Chair of the House Committee on the Budget. In recent years, the Congressman has been especially critical of the Affordable Care Act and mandatory physician participation in alternative payment models.
The mission of HHS is to enhance and protect the health and well-being of all Americans by providing for effective health and human services and fostering advances in medicine, public health, and social services. HHS has eleven operating divisions, including eight agencies in the U.S. Public Health Service and three human services agencies. The Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), the National Institutes of Health (NIH) and the Food and Drug Administration (FDA) fall under the HHS umbrella.
Price’s appointment is pending confirmation by the full Senate.
ICD-10 Code Updates and Impact to PQRS
On October 1, 2016, new ICD-10 codes went into effect. As a result of this coding update, the Centers for Medicare and Medicaid Services (CMS) announced that the ICD-10 code updates will impact their ability to process data reported by physicians on certain quality measures for the fourth quarter of 2016. As a result, CMS will not apply the 2017 or 2018 Physician Quality Reporting System (PQRS) penalties to any individual eligible professional or group practice that fails to satisfactorily report for 2016 solely as a result of the impact of ICD-10 code updates on quality data reported for the 4th quarter of 2016. Eligible professionals and group practices must still report PQRS data; if after the data is reported, the eligible professional or group practice does not meet PQRS reporting requirements based solely as a result of the ICD-10 updates, CMS will not apply PQRS penalties.
For More Information:
FDA Reclassifies Pedicle Screw Systems
In late December, the U.S. Food and Drug Administration (FDA) issued a final order taking several actions to reclassify pedicle screw systems. Under the order, the FDA downgraded pedicle screw systems from a class III device to a class II device, renamed the device “thoracolumbosacral pedicle screw systems,” renamed and reclassified dynamic stabilization systems as “semi-rigid systems” into class II, and clarified the device identification of pedicle screw systems to more clearly delineate rigid pedicle screw systems from semi-rigid systems.
The final order comes after a 2014 proposed order to reclassify pedicle screw systems and a two-year review process. The final order means that the FDA believes the clinical performance data special control and other special controls, together with general controls, are sufficient to provide a reasonable assurance of safety and effectiveness of these devices.
ISASS Policy & Advocacy News will be on a brief hiatus and will return to your inbox in June 2017.