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Coding for insertion of an interspinous process decompressive device

JustCoding News: Inpatient, June 9, 2010

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by Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P

The X-STOP® procedure, which refers to the insertion of an interspinous process decompressive (IPD®) device, is becoming a popular method of treatment for lumbar spinal stenosis. This procedure is less invasive than the traditional surgical treatment for those who have undergone nonsurgical treatments such as physical therapy and therapeutic injections and have reached the point where they require surgery.

The insertion of an interspinous process decompressive device such as the X-STOP spacer device decompresses a patient’s spine, which is necessary to  relieve their pain. It also involves a shorter recovery period and is less invasive than traditional surgical treatment for lumbar spinal stenosis, which would be a laminectomy/laminotomy or foraminotomy, potentially including spinal fusion. Some patients may also be eligible to have the procedure performed on an outpatient basis. Many surgeons, however, do perform X-STOP procedures on an inpatient basis, so we will discuss the coding for inpatient hospital coders as well as the physician service coding for inpatients or outpatients.

To insert an IPD device, the physician usually makes a posterior midline incision. The physician may need to remove bone or ligament to make space for insertion of the device, although one of the stated benefits of the X-STOP is that they typically do not require bone removal. Any such removals are typically minimal.

The physician then exposes the appropriate spinal processes and verifies the potential placement of the device radiologically. The physician will then dilate the interspinous ligament and place and secure the decompression device. Providers can perform this procedure under local anesthesia, which is usually accompanied by sedation.

The Food and Drug Administration has approved the X-STOP device for marketing, but as is the case with any medical service or treatment, some payers don’t reimburse for the X-STOP procedure. Physicians and hospitals should verify coverage with their third-party payers, some of whom consider the procedure investigational, prior to performing the procedure.

Hospital coding

Inpatient hospital coders should report ICD-9-CM procedure code 84.80 (insertion or replacement of interspinous process device[s]) for the X-STOP procedure. Although ICD-9-CM diagnosis codes will obviously vary based on the patient’s medical record documentation, many patients who undergo the X-STOP procedure will have a diagnosis of spinal stenosis in the lumbar region (ICD-9-CM code 724.02).

Barring any additional CCs or MCCs, or other surgical procedures that may alter the DRG, the reimbursement for a Medicare patient admitted for an IPD insertion will most likely be grouped to MS-DRG 490 (back and neck procedures except spinal fusion with CC/MCC or disc devices or neurostimulator). Obviously, patients who undergo other procedures or with CCs may have other code assignments that will result in a different MS-DRG assignment.

Medicare allows for payment for IPD insertion, however different Medicare contractors may have local coverage determinations (LCD) that affect coverage for these types of procedures. Some commercial and other third-party payers allow payment as they would for a traditional laminectomy, whereas others still consider these procedures investigational.

When providers admit patients for IPD insertion procedures, case management or utilization review staff members should verify coverage with the patient’s payer to ensure that the patient’s insurer will cover the service. Also, not all patients will meet medical necessity criteria for inpatient admission when having this procedure performed. You will want to not only verify that the service is covered under the patients plan, but that they would be eligible for inpatient coverage for the service prior to admission for the elective surgical procedure.

This procedure is also covered under the outpatient prospective payment system as a status indicator T procedure, meaning that it has coverage under this Medicare payment system as a surgical procedure that is subject to multiple procedure discounting. Again, verify the LCDs to verify that patients will have coverage for these services at your facility.

Coding for physician services

For the physician coding side of the procedure, report CPT category III code 0171T (insertion of posterior spinous process distraction device [including necessary removal of bone or ligament for insertion and imaging guidance], lumbar; single level) and CPT category III code 0172T (each additional level).

However, some third-party payers require that providers use code 22899 (unlisted procedure, spine) instead of CPT category III codes. Make sure you verify with each payer how it prefers for you to code these services. Also, ensure that you use the appropriate place of service code for the location of the procedure (e.g., 21 for inpatient hospital, 22 for outpatient hospital).

CPT codes 22102 and 22103, which some physician practices have reported for IPD device placements, are for the partial excision of a bony lesion. These codes are not appropriate for reporting the X-STOP procedure.

Medicare does not assign relative value units to category III codes under the Medicare physician fee schedule. Therefore it falls to the discretion of the Medicare contractor to decide whether to pay for these services, and if so how much. Although you may process your hospital and physician claims through the same Medicare administrative contractor, the physician side (Part B) may have different LCDs than the facility side (Part A). Hospitals and physician practices should check the LCDs independently to verify coverage for their services.

Editor’s note: Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, is an adjunct instructor for the Certified Coder Boot Camp® (covers physician and outpatient hospital coding) and the Medicare Boot Camp for Hospitals, both live and online versions for HCPro, Inc. Harrington is also the president and CEO of ComplyCode, a healthcare compliance consulting firm based in Binghamton, NY. E-mail her at jharrington@complycode.com.



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