CPT Editorial Panel Updates for Spine: Key Concepts for 2015


Earlier this year, the American Medical Association's CPT Editorial Panel announced it will make a few significant changes for spinal procedure coding in 2015.

While the specific changes won't be detailed until later this year, the Editorial Panel says there will be changes to minimally invasive sacroiliac joint fusion coding, artificial disc replacement coding and vertebral augmentation coding.


Minimally invasive sacroiliac joint fusion is currently reported by a Category III CPT code, 0334T. The AMA created this procedure code effective July 2013. At the recent Editorial Panel meeting it was determined that the procedure had satisfied the evidence threshold necessary to transition to a Category I CPT.  Effective January 1, 2015 a  Category I CPT code will be implemented to describe percutaneous/minimally invasive sacroiliac joint arthrodesis.


"I think it's important for patients and spine surgeons to know this information now to open a dialogue with various insurance carriers across the nation," says Morgan Lorio, MD, Chair Coding & Reimbursement Task Force for the International Society for the Advancement of Spine Surgery (ISASS). "We've gone from a Category I to Category III and back to Category I code with this procedure in about a year period. I think that speaks to the fact that the medical terrain is changing at a phenomenal rate, and physicians and industry are responding quickly to answer questions about the effectiveness of their procedures."


ISASS has worked diligently the past year to provide the AMA with the information they require to establish a Category I Code for MIS SI joint fusion. ISASS, in conjunction with the Society for Minimally Invasive Spine Surgery (SMISS) collaborated in a survey to its U.S. membership to determine the prevalence of the MIS procedure. This published survey established that MIS SIJ fusion had evolved as the standard of care to treat non-trauma related disorder of the sacrum. Strong data and studies are becoming more important to payers and other stakeholders in healthcare today, and professional societies are rising to the challenge.


"Physicians and industry are responding to create and acquire sound data supporting procedures that weren't previously questioned," says Dr. Lorio. "Industry and physicians are carrying even more of the burden to try to prove what they are doing is warranted, efficacious and have value proposition."


The ISASS website currently includes directives on how surgeons, patients and payers can handle coding minimally invasive SI joint fusions now and next year.


The AMA Editorial Panel also announced a new Category I CPT code for two-level cervical total disc arthroplasty. The procedure was previously reported by a Category III CPT code. The transition to a Category I Code will allow for the existing Category III CPT code to be updated to describe a three- or more-level arthroplasty.


"Total disc arthroplasty showed sufficient data to add an additional level to the Category I code;  ISASS Policy Statement – Cervical Artificial Disc is IN PRESS with the International Journal of Spine Surgery (IJSS)” says Dr. Lorio.


Several compounding factors have slowed spine innovation, and now approved procedures must show both clinical and cost-effectiveness over the current standard of care. New products must mitigate or negate risk to move forward.


"We are really moving away from equivalence data and more to superiority where possible," says Dr. Lorio. "If someone is to make it to the market, the product must bring everything to bear; every econometric measure from being minimally invasive to impacting the length of stay and improving results. It will have to do all that at the same price as what surgeons are currently using if it's going to be reimbursed."


ISASS has a task force group assigned to respond quickly to reimbursement-related issues, and along with input from its members, the organization seeks to influence policymakers on spine procedure decisions. They participate with studies, policy statements, coverage criteria, and published scientific papers.


"By creating coverage guidelines for spine procedures, ISASS is fostering relationships with payers with the anticipation of positioning themselves as partners to help develop guidelines for medical necessity," says Kelli Hallas, a reimbursement consultant and member of the ISASS Coding & Reimbursement Task Force. "As technologies are developed our goal is to partner with the payer community to assist in the creation of initial coverage guidelines. We want to allow surgeons to provide the best treatment for their patients and we want patients to continue to have access to the appropriate care."


ISASS anticipates becoming a member of the House of Delegates for the CPT Editorial Panel discussions this summer. "We are looking forward to our participation in the House of Delegates. There I think we'll be in a better position to do what we are currently attempting to do: support physicians and give patients a clear route to access while supporting reimbursement for the procedures they need. ISASS is Transformative Leadership, literally re-inventing spine. ISASS embodies innovative spine vision coupled with concrete achievement and integrated transparency," says Dr. Lorio.


More Articles on Spine Surgery:
How Spine outcomes Registries Are Transforming Treatment
Combat Spine Practice Regulatory Burden: Core Concepts to Optimize Efficiency
Healthcare Economics: 8 Ways Spine Surgeons Can Make a Difference

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