Health Information Management

Q/A: New code for image-guided minimally invasive lumbar decompression

APCs Insider, August 12, 2011

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Q: Has CMS provided any updates regarding image-guided minimally invasive lumbar decompression (IG-MLD) for spinal stenosis?

A: Percutaneous IG-MLD using a specially designed tool kit (mild®) has been proposed as an ultra minimally invasive treatment of central lumbar spinal stenosis (LSS).
In this procedure, physicians fill the epidural space with contrast medium under fluoroscopic guidance.

Using a 6-gauge cannula clamped in place with a back plate, physicians employ single-use tools (portal cannula, surgical guide, bone rongeur, tissue sculpter, and trocar) to resect thickened ligamentum flavum and small pieces of lamina. The tissue and bone sculpting occurs entirely under fluoroscopic guidance, with additional contrast media added throughout the procedure to aid visualization of the decompression. The process is repeated on the opposite side for bilateral decompression of the central canal.

Use CPT® category III code 0275T (percutaneous laminotomy/laminectomy [intralaminar approach]) for decompression of neural elements) that became effective July 1, to report this procedure. This code falls under APC 0280 with a national payment of $3,535.92.

Note, however that just because a CPT code with payment under OPPS does not imply automatic CMS coverage. Transmittal 2234 states:

The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure or service may be paid if covered by the program. Fiscal Intermediaries (FIs)/Medicare Administrative Contractors (MACs) determine whether a drug, device, procedure or other service meets all program requirements for coverage.

Use the following steps as you exercise your own internal and external due diligence beyond CPT® code selection to secure revenue integrity:

  1. Review current and be aware of new Local Coverage Determinations (LCD) from your FI/MAC to ensure coverage and requirements. Remember to give patients an Advanced Beneficiary Notice of Non-Coverage (ABN) form before performing noncovered procedures.
  2. Include your top five third-party payers and inquire about their coverage determinations. Many of their policies consider new technology and procedures as experimental, investigational, and noncovered.
  3. Upon determining coverage, inform your physician staff, clinicians, registration staff, pre-certification department, and health information coding staff of coverage findings and proceed accordingly.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, president of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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