The 2020 Medicare Physician Fee Schedule includes a big win for minimally invasive sacroiliac joint fusions: a 27 percent rate increase by CMS.
The fee schedule updates the payment rate for CPT 27279 by 27 percent and increases the work relative value units associated with the CPT code from 9.03 to 12.13. After the adjustments, surgeon pay for the procedure increases from $720 to $915 as of Jan. 2, 2020.
The changes to more appropriately value the procedure will bring it to the forefront as a great option for spine surgeons and specialists who treat lower back pain patients.
"The increased reimbursement will enable surgeons to diagnose and treat back pain in a better way," said Morgan Lorio, MD, a spine surgeon with Advanced Orthopedics of Florida in Altamonte Springs. "From a societal perspective, the pay increase will improve patient access to minimally invasive SI joint fusions. You are also going to see improved traction for MIS SI joint fusion devices across all manufacturers, and I think sales will increase dramatically."
CMS initially proposed the rate increase earlier this year and sought comment from the public; but the change is a long time in the making. Dr. Lorio has spent time over the years advocating for the change on Capitol Hill and at the White House, pointing out that the undervalued MIS procedure may lead surgeons to perform the more invasive open SI joint fusions.
The International Society for the Advancement of Spine Surgery has worked on behalf of patients and surgeons to improve access to the procedure. Dr. Lorio has co-authored studies 1) outlining the benefits of the MIS procedure, 2) describing the work, and 3) describing the intensity of performing MIS SI-joint fusions, arguing it was previously undervalued. ISASS and Dr. Lorio argued that when the RUC initially valued MIS SI joint fusions in 2015, the crosswalk should have been compared to CPT 63030, an open discectomy, instead of a percutaneous procedure. With its 2020 final rule, CMS agreed.
"In my experience, CMS is keenly looking at patient access dynamics to effective procedures and trying very hard to get things right for the patients, physicians and hospitals," said Jeffrey Zigler, vice president of market access and reimbursement for SI-BONE. "In this case, there was lots of information and input. As I understand, RUC surveys for procedures such as these usually have 30 to 50 responses, but when CMS asked for stakeholder input on this topic there were more than 80 comments from surgeons."
However, in the five years since the RUC initially valued and underpaid MIS SI joint fusions, damage has been done. The RUC used its determination for MIS SI joint fusions as a benchmark for determining subsequent values for new spinal procedures and undervalued them as well.
"There is a lot of intensity associated with performing minimally invasive procedures; if things go wrong, the surgeon suffers stress and frustration," said Dr. Lorio. "It's crazy how CMS undervalues emerging technology that is so intense. Hopefully now that this is appropriately valued, it will serve as a better benchmark going forward."
The new code value could make MIS SI joint fusions attractive in the ASC as well. Mr. Zigler anticipates more surgeons will be interested in performing the procedure and has ramped up education efforts as well as increased resources in medical affairs to meet the demand of more surgeons training.
"The most important aspect is to help surgeons and all healthcare providers who treat lower back pain understand that a full differential diagnosis of lower back pain should in most cases include the sacroiliac joint, given that it represents approximately 15 percent to 30 percent of chronic lower back pain," he said. "In my opinion, the most important thing in spine is to get the diagnosis and precise as possible."
References
1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3924210/
2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5374999/
3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968979/