Medicare Billing for Spine Surgery in ASCs May be Tricky This Year

by | Last updated Feb 28, 2024 | Published on Dec 4, 2015 | Medical Billing

Spine Surgery
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The Centers for Medicare and Medicaid Services (CMS) added several new codes for spine surgery on the ambulatory surgery centers (ASC) payable list this year. It is important for all Ambulatory surgical center billing companies to be aware of. This is a very crucial step as young Medicare patients can have their surgeries at surgery centers at lower cost and higher quality than hospitals. More commercial payers will start reimbursing for these newly added procedures as it is now possible for them to base reimbursement on a percentage of Medicare. However, medical billing for Medicare patients undergoing surgery at ASCs is going to be tricky in 2015. This is mainly because CMS failed to add certain codes for spinal procedures commonly performed together with the newly added codes in ASC 2015 payment rule.

The Challenges

In the ASC 2015 payment rule, the following spine codes are added by the CMS as separately payable, effective from January 1, 2015.

  • 22551 (Neck spine fuse and remov bel c2)
  • 22554 (Neck spine fusion)
  • 22612 (Lumbar spine fusion)
  • 63020 (Neck spine disk surgery)
  • 63030 (Low back disk surgery)
  • 63042 (Laminotomy single lumbar)
  • 63045 (Removal of spinal lamina)
  • 63047 (Removal of spinal lamina)
  • 63056 (Decompress spinal cord)

CMS added two other codes, 22614 (Spine fusion extra segment) and 63044 (Laminotomy, additional lumbar) into the ASC payable list as well, which are not separately payable as these codes have been packaged with other codes in the list. In addition to this, CMS agreed to the assessment of the Ambulatory Surgery Center Association that the codes 22551, 22554 and 22612 were assigned to the wrong ambulatory payment classification (APC) group in the proposed rule and moved these codes to APC 0425. This group has a higher reimbursement compared to the group to which they were originally assigned. All these changes brought about the following challenges to ASCs.

  • When it comes to spine cases, there would be multiple codes associated with a particular case most of the times. The new additions have made the billing procedures tricky as some codes are separately payable and some are not.
  • Typically, Medicare provides significantly less reimbursement to ASCs compared to hospitals and hospital outpatient departments. So, it is very important to keep a check on the costs of procedures performed and ensure there are no significant cuts in the profit margin to avoid loss. You have to pick and choose the procedures carefully to manage the costs.

In short, codes for spinal surgery procedures must be chosen with great care in this scenario if providers are to receive the due reimbursement. You must either train your medical coders well regarding the new payment rule or obtain reliable support from medical billing and coding companies with sufficient experience and expertise to avoid mistakes and claim denials.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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