The Central Office often receives requests for coding advice pertaining to spinal procedures, including spinal fusions. Many of these procedures are open procedures, performed on an inpatient basis and are included on the Medicare Inpatient Only (IPO) list. Although we get many requests for HCPCS coding assistance pertaining to these types of procedures, we are generally not able to respond as our services are limited to providing coding assistance for outpatient facility coding questions only since ICD-10-PCS is the HIPAA standard for hospital inpatient reporting. As a reminder, coding questions we can respond to include the following:
- Level I HCPCS (CPT-4 codes) for hospital providers
- Level II HCPCS codes for hospitals, physicians and other health professionals who bill Medicare
We cannot provide assistance for physician or inpatient CPT code reporting. While traditionally spine procedures have been performed in the inpatient setting, as technology has advanced, there are spine procedures that are performed in the outpatient setting. A couple of factors that may help determine if a procedure is typically inpatient or outpatient is approach (percutaneous, endoscopic, open), and visualization (direct and indirect). Effective January 2017, definitions were added to the CPT codebook to help identify these concepts. The definitions are as follows:
- Percutaneous — Image-guided procedures (e.g., computer tomography [CT] or fluoroscopy) performed with indirect visualization of the spine without the use of any device that allows visualization through a surgical incision.
- Endoscopic — Spinal procedures performed with continuous direct visualization of the spine through an endoscope.
- Open — Spinal procedures performed with continuous direct visualization of the spine through a surgical opening.
- Indirect visualization — Image-guided (e.g., CT or fluoroscopy) not light-based visualization.
- Direct visualization — Light-based visualization; can be performed by eye, or with surgical loupes, microscopy or endoscope.
Open procedures with direct visualization of the operative site, are typically performed in the inpatient setting. These procedures are invasive and tend to require additional care and longer recovery times. A CPT code that would fall under this category, for example, would be 22558, Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar, which is also included on the Medicare Inpatient Only List. It is important to note, that CPT codes are considered open procedures unless otherwise specified.
Examples of codes that include a specified approach are CPT code 62380, Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar. The narrative for this code specifically states an endoscopic procedure, therefore, the documentation should support continuous visualization through a scope in order to correctly assign this code.
An example of a procedure performed percutaneously, if supported by the documentation, could be CPT code 0275T, Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar. As defined, a percutaneous approach indicates an image guided procedure, the surgeon has no direct visualization of the operative site.