Having received several denials of payment after billing for spine surgery,
a reader recently requested clarification about the appropriate use of lumbar
discectomy and decompression codes when also performing a posterior lumbar
interbody fusion, PLIF. The specific Current Procedural Terminology codes involved
are 22630 with 63047, and code 22630 with 63030.
Both private and governmental payers are more closely scrutinizing coding
combinations for potential overlap, and unfortunately a simple method of correctly
coding them does not exist. However, payers unilaterally can choose to bundle
certain procedures, and CPT rules and Relative Value Scale Update Committee
vignettes and surveys can serve as a basis for making these decisions.
The CPT descriptor for code 22630, PLIF, summarizes the procedure as an arthrodesis
performed using a posterior interbody technique that includes laminectomy and
discectomy to prepare the interspace at a single level. The descriptor was
revised with an editorial change a number of years ago to include the parenthetical
"other than for decompression,"reflecting the possible performance of laminectomy
or discectomy for decompression in addition to the PLIF. The National Correct
Coding Initiative Coding Policy Manual for Medicare Services under most circumstances
bundles with PLIF 22630: lumbar discectomy 63030; lumbar laminectomy without
facetectomy 63005 (one or two levels); 63017 (more than two levels); Gill laminectomy
63012; and lumbar laminectomy with facetectomy 63047. A prior NCCI edit bundling
PLIF 22630 with posterolateral lumbar fusion 22612 was reversed after an appeal
was made to the contractor managing the NCCI process. Last year, a Blue Cross
and Blue Shield carrier in the Midwest published an advisory regarding bundling
the decompression code 63047 with PLIF, citing the NCCI Coding Policy Manual
as well as the American Academy of Orthopedic Surgery Global Service manual.
Since the descriptor for PLIF specifically addresses the work of laminectomy
and discectomy for performing the PLIF, it is important to analyze the vignette
that more completely describes the clinical setting for which PLIF was valued.
The "typical patient" vignette that was the basis for valuing 22630 at the
most recent Relative Value Scale Update Committee meeting involves a middleaged
man with prior discectomy and posterolateral fusion who has pseudoarthrosis,
intractable back pain, and minimal signs of nerve root dysfunction. The surgical
work includes previous operative site exposure to the facets with removal of
scar tissue; extension of the prior laminectomy as well as medial facetectomy;
nerve root mobilization from surrounding tissues, including scar tissue; removal
of cartilaginous endplates; and insertion of graft material. This procedure
is performed bilaterally in sequence. Graft harvest and spinal instrumentation
are considered possible separate additional procedures. Based upon the surgical
work involved, a significant portion of laminar, facet, and disc removal are
considered components of PLIF.
However, the typical patient does not have signs of nerve root dysfunction.
If symptomatic nerve compression is present and treated, how does one categorize
the surgical work? Sometimes, the tissue removal needed to perform the PLIF
safely also decompresses the spinal canal and lateral recesses. For example,
the bilateral threaded cage or bone dowel technique necessitates complete or
near complete facetectomy with significant mobilization of the the cal sac
and nerve roots, leaving no additional bone or other tissue to remove for decompression.
The difficulty in categorizing this work lies in the variety of ways that interbody
fusions are currently performed. For example, a unilateral transfacet approach
can be used for a posterior interbody technique. While this technique does
not require any tissue removal on the contralateral side, it also reflects
a reduced service from the PLIF procedure, which was valued as a bilateral
approach. It obviously is difficult to summarize every clinical variation in
a single CPT code. Since a nearly total discectomy is necessary for preparing
the interspace for arthrodesis, one can infer that posterior lumbar discectomy
63030 and re-exploration discectomy 63042 would be included in PLIF 22630 under
nearly all circumstances. Similarly, medial facetectomy (63012 and 63047) and
laminectomy (63005 and 63017) to expose and mobilize the traversing nerve root
(and perhaps the exiting nerve root) also typically would be included in the
work required to perform a PLIF. These exposure and disc space preparation
activities incidentally and concurrently result in decompression of the spinal
canal and nerve roots.
Despite the typical inclusion of these decompressive procedures in PLIF, there
may be clinical circumstances in which symptomatic compression exists lateral
to the exposure needed to perform the PLIF. For example, an extraforaminal
compression of the exiting nerve root would require exposure and tissue removal
solely for the purpose of decompression. Since there are circumstances that
require additional decompression beyond what is already required to perform
a PLIF, the NCCI system allows for use of bundled decompression codes by applying
modifier -59 to demonstrate the distinct surgical site in which the decompression
The coding combinations for decompression and PLIF have been the source of
confusion and numerous questions over the past decade. Revision of the single
CPT description of PLIF to reflect the variety of techniques and technological
advances that have evolved to perform this procedure has been considered. However,
the evolution of CPT and the valuation of procedures by the Relative Value
Scale Update Committee are lengthy and unpredictable processes that are unlikely
to simplify this area of coding confusion in the near future.
Gregory J. Przybylski, MD, chair of the AANS/CNS Coding and
Reimbursement Committee, represents the AANS on the American Medical Association's
Relative Value Scale Update Committee. He instructs coding courses for the
AANS and for the North American Spine Society. He is a member of the Practicing
Physicians Advisory Council to the Centers for Medicare and Medicaid Services,
and he is a consultant to United HealthCare and Humana Inc.