Bulletin:   2008 (Volume 17, Issue 3)

Perplexing PLIF: Coding Combinations Leave Coders in Doubt

By:   Gregory J. Przybylski, MD

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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 is performed.

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.

Article ID: 55461
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