Spine surgeons are paying attention to developments in procedure codes, which can affect how patient care is documented and billed.
Here are the key updates and proposals in spine coding since 2022:
2024
CMS is proposing eight new MS-DRGs to delineate single and multilevel lumbar fusions. These are expected to better track resource utilization for specific procedures and adjust hospital payments for resources behind multilevel fusions.
Another proposal is looking into an episode-based alternative payment model called the Transforming Episode Accountability Model. The TEAM model is expected to go into effect at the start of 2026. Participating hospitals will use it to manage total costs of care for spinal fusions and compare them to target CMS costs over four years.
New updates in the family of ICD-10-CM codes will provide further specifications for back pain. The ICD-10 Coding Committee released a new set of diagnostic codes to specifically describe intervertebral disc degeneration with discogenic pain, a spokesperson for the International Society for the Advancement of Spine Surgery told Becker's. The payment rule was released April 10 and will take effect Oct. 1.
2023
UnitedHealthcare eliminated prior authorization requirements for four spine-related codes. The codes were eliminated for UnitedHealthcare Medicare Advantage, UnitedHealthcare commercial, UnitedHealthcare Oxford and UnitedHealthcare Individual Exchange plans. Codes were eliminated for the UnitedHealthcare Community Plan as well.
The American Medical Association issued a CPT add-on code for the second level in lumbar total disc procedures. The code went into effect Jan. 1, 2023, and applies to two-level total lumbar disc replacement using an anterior approach, according to a news release. Centinel Spine's Prodisc L is the only total disc replacement in the U.S. approved for two-level use in the lumbar spine.
The International Society for the Advancement of Spine Surgery successfully pushed for the deletion of Medicare Correct Coding Initiative edits for new CPT codes for lumbar decompression for transforaminal lumbar interbody fusion and posterior lumbar interbody fusion.
2022
A category 3 CPT code for sacroiliac joint fusion was created and went into effect in July 2023. The code is for the minimally invasive insertion of a device into the intra-articular SI-joint space.