CMS Announces Retroactive Reimbursement

CMS Announces Retroactive Reimbursement

Spinal fusion codes are back and unbundled

CMS has announced that it is retroactively reimbursing denied claims for two major Spine Fusion procedures.

In April 2006, CMS implemented a CCI edit disallowing the reporting of CPT-4 code 22612, with CPT-4 code 22630. This "Bundle" represented a noticeable reduction in reimbursement for physicians and contradicted documents later used to support the medical necessity of performing these procedures together. In a move to improve patient care and reduce the cost of providing care, CMS has decided to revoke the CCI edit retroactively.

CPT Code


Description

MC Average Payment Rate

22612

Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)

$1,492.43

22630

Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace (other than for decompression), single interspace; lumbar

$1,469.60

* Standard payment adjustment rules for multiple procedures apply.

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Despite their initial decision to bundle the two arthrodesis codes, CMS reviewed comments submitted from various specialty societies regarding the appropriateness of performing these procedures during the same operative encounter. Specialty societies such as NASS, AANS and CNS requested reconsideration of the CCI edit along with submitting documentation supporting the medical necessity and indications for performing these procedures together.

Effective October 1, 2006, CMS will reimburse physicians for all dates of service that were denied beginning April 1, 2006.

Physicians should gather all claim denials related to this edit and resubmit claims to their local carriers for processing and payment. Physicians should also check for any denials from commercial payors as they also utilize the CCI edits when reviewing claims for payment.

This CMS CCI edit rule change identifies the importance of solidified and clinically relevant responses to Medicare. This move is also part of a larger strategy by CMS to move towards paying physicians based on the quality of care they are providing. Former CMS Administrator, Mark B. McClellan states, "This is another important step toward paying for what we really want: better care at a lower cost, not simply the amount of care provided."

Physicians need to monitor CMS's P4P initiatives and begin collecting patient outcomes data. The information and outcomes you are currently generating may sustain your future reimbursement.

Brief History of CCI Edits: The Centers for Medicare and Medicaid Service (CMS) implement National Correct Coding Initiative edits (CCI edits) deemed necessary to prevent the unbundling of services for erroneous payment purposes.

These edits are intended to identify what they believe to be overlapping or duplicate work performed during a single procedure. Recently, CMS CCI edit criteria has been increasingly reflective of the medical necessity parameters that support performing multiple procedures together. This methodology is in synch with their efforts to implement performance-based reimbursement for physicians, Pay for Performance or P4P.

For more information on the"Performance-Based Payments for physicians", please see the CMS Press release.

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Article written by: Marcy Rogers, M.Ed.