10 Spine Procedure Coverage & Reimbursement Updates Featured

Written by  Laura Dyrda | Thursday, 13 February 2014 16:15
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SpineHere are 10 recent spine surgery and interventional back pain procedures with coverage updates.

1. Aetna revised coverage on medical necessity for spinal cages to include coverage for "medically necessary" cervical spinal fusion for members that meet specific criteria. Last year, the insurer considered changing its medical necessity policy for spinal cages to include use with autogenous bone graft patients meeting the criteria for spinal fusion and thoracic fusion, but excluding cervical fusion; however the revised policy released in 2014 includes limited criteria for cervical cases.


2. The National Coverage Analysis for percutaneous image-guided lumbar decompression issued a decision not to cover the procedure for patients with spinal stenosis. CMS will not cover the procedure and the American Association of Neurological Surgeons and Congress of Neurological Surgeons support this decision, as the literature has not proven patients receive better outcomes from PILD, according to a letter from the organizations.


3. Despite the lack of coverage for PILD procedures, patients enrolled in the approved CED clinical study for VertiFlex's Totalis Direct Decompression System will be able to receive Medicare coverage for the procedure. CMS has decided to extend coverage to patients in the investigational trial.


4. The CPT Editorial Panel made statements in mid-2013 supporting the assignment of a CPT Category III code to minimally invasive sacroiliac joint fusions. As a result, the procedure is not considered experimental, but the new technology will be tracked for data collection. According to a report from the International Society for the Advancement of Spine Surgeons and Society of Minimally Invasive Spine Surgeons, 90 percent of SI joint fusions are performed using a minimally invasive approach.


5. The 2014 CMS Final Physician Fee Schedule Rule revised upward the Practice Expense Relative Value Unites for CPT Code 22586 for pre-sacral interbody fusion to increase the RVUs for the code by 18 percent over the 2013 RVUs. The procedure, which can be performed with Baxano Surgical's AxiaLIF Plus implant, is now 53.76 RVUs.


6. Health Care Services Corporation announced in February 2014 it will reimburse for MiMedx's EpiFix allograft, a device with use in wound care, soft tissue replacement and surgical treatment in the spine and knees. There are currently 12 state Medicaid programs that also reimburse for EpiFix.


7. The 2014 CMS Final Physician Fee Schedule Rule significantly reduced reimbursements for several interventional pain procedures, including cuts for cervical and lumbar epidurals. Physicians now receive $42 payment for performing these procedures.


8. The 2014 CMS Final Physician Fee Schedule Rule that included payment rate decreases for physicians performing spinal cord stimulation in-office trials. However, facilities supporting procedures will receive an increase. Beginning Jan. 1, 2014, physicians were required to bill CPT 63650 for each lead implanted, which has been revalued to include the cost of trial leads. Additionally, CMS will pay the highest value CPT code at 100 percent and each additional CPT code at 50 percent, according to a report form St. Jude Medical.


9. In December of 2013, the Blue Cross Blue Shield of Tennessee dropped its plan for non-coverage of cervical epidurals. Their draft policy state epidural steroid injections for treating pain were considered investigational, but BCBS of TN decided not to finalize the policy and cervical epidurals will remain covered, according to a report from the International Spine Intervention Society.


10. ISIS also reported last year that Tennessee Medicaid reversed its non-coverage policy for facet interventions.


More Articles on Spine Surgery:
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Boutique Spine Practice: An Answer to Healthcare Reform
Spine Surgeons Top Orthopedic Specialist Average Salary


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