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A brief review of the challenge faced by practicing spine surgeons: When an interbody fusion is performed in the lumbar spine, the interbody fusion codes (CPT® codes 22630 and 22633) include the bone removal to access the disk space and complete the interbody arthrodesis. Sometimes, patients have stenosis producing neurogenic claudication where more decompression work is required. The additional decompression of neural elements adds additional time and additional risk. Before January 2015, surgeons would report the additional decompression of neural elements (more than required for access to the disk space for the interbody fusion) with the lumbar laminectomy code (63047) with an appropriate modifier. This approach to procedure reporting was eliminated after a National Correct Coding Initiative (NCCI) edit published on Jan. 1, 2015. With this edit, physicians could not report the work performed when a decompression was performed at the same level as an interbody fusion. Potential solutions were investigated, including using the additional level laminectomy code (+63048). Hospital compliance departments and private payers refused to bill or pay for +63048 for these cases. While championed by another spine society, using +63048 was not an appropriate or viable solution. As described, +63048 is an add-on code essentially paired to 63047.

After discussion with NCCI and Center for Medicare & Medicaid Services (CMS) leadership, the American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), and AANS/CNS Section on Disorders of the Spine and Peripheral Nerves (DSPN) developed a new set of codes that described the decompression performed at the same level as a concurrent interbody fusion (CPT codes 63052 and 63053). AANS/CNS Coding and Reimbursement Committee leaders refined the figures describing these new procedures. These figures were included in the 2022 CPT and illustrated the separate and distinct work performed in the new codes (Figure 1). The new codes were developed with other spine societies and valued. They became available for use by spine surgeons on Jan. 1, 2022. Illustration developed with American Association of Neurological Surgeons and Congress of Neurological Surgeons guidance demonstrates the separate and distinct work involved in accessing the interbody space compared with the area of work needed for decompression of the neural elements. Although these areas are contiguous, decompression of these spinal elements involve different levels of risk and time. TLIF, transforaminal lumbar interbody fusion.

es the separate and distinct work involved in accessing the interbody space compared with the area of work needed for decompression of the neural elements. Although these areas are contiguous, decompression of these spinal elements involve different levels of risk and time. TLIF, transforaminal lumbar interbody fusion. However, the addition of these new decompression codes did not conclude the story. When valuing the new codes, the American Medical Association/Specialty Society RVS Update Committee (RUC) requested a resurvey and revaluation of the foundational interbody fusion codes. The new decompression codes became available, but their value remained in flux. With new surveys, the interbody fusion codes also faced potential devaluation.

The requested surveys of interbody fusion procedures were completed and reviewed. The new surveys showed that the total time required for the interbody fusion procedures was lower. Neurosurgery's coding and reimbursement experts argued that this did not connote a decrease in physician work or a reduction in the complexity of these surgeries. Rather, the decrease in time arose from improved efficiency in the low-intensity/low-risk aspects of the procedure. Examples of these improved efficiencies include using fluoroscopy instead of plain films and using an electric drill instead of a pneumatic drill with change in air tanks. The key elements of the interbody fusion codes, and the risks of performing an interbody fusion, did not change. After extensive review, the RUC concurred and forwarded CMS recommendations for minor decreases in interbody fusion codes' value.

CMS disagreed and did not follow the valuations suggested by the RUC and its expert panel. The proposed 2023 Medicare Physician Fee Schedule included a ∼10% reduction in the valuation of the interbody fusion codes. If finalized, physician work would have been undervalued by this change. The AANS, CNS, and DSPN responded. AANS/CNS Washington Office staff (Catherine Jeakle Hill) arranged a meeting with CMS leadership and neurosurgery's Coding and Reimbursement Committee experts (Joseph S. Cheng, MD, FAANS; John K. Ratliff, MD, FAANS; Luis M. Tumialán, MD, FAANS; and others). Neurosurgery was joined in the call by the International Society for the Advancement of Spine Surgery and other societies. Discussions with CMS leadership were very cordial, and our arguments supporting the RUC position were reviewed.

In the final rule setting code values for 2023, CMS accepted the RUC recommendations and returned the interbody fusion codes to higher valuations (https://www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other). These changes allow appropriate reporting and valuation of physician work. CMS change in the value of the interbody fusion codes represents a huge victory for spine surgeons and spine surgery patients. These additional decompression codes will help ensure that Medicare patients have access to medically necessary spine procedures.