DRAFT LCD Reference Article Billing and Coding Article

Billing and Coding: Cervical Fusion

DA59674

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Note History

Contractor Information

Draft Article Information

General Information

Source Article ID
N/A
Draft Article ID
DA59674
Original ICD-9 Article ID
Not Applicable
Draft Article Title
Billing and Coding: Cervical Fusion
Article Type
Billing and Coding
Original Effective Date
N/A
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Internet-Only Manuals (IOMs)

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)

 National Correct Coding Initiative (NCCI):

  • Medicare NCCI Policy Manual,
    • Chapter 1, General Correct Coding Policies for Medicare National Correct Coding Initiative Policy Manual

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text


This Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL39799 Cervical Fusion. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

This article applies only to cervical fusion and related procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).

Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. The patient’s medical record should include, but is not limited to:
    • The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.
    • Relevant medical history.
    • Results of pertinent tests/procedures.
    • Signed and dated office visit record/operative report. (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
      • The operative note should include the procedure performed and any associated/additional procedures performed at the same time.
    • Documentation to support the medical necessity of the procedure(s).

Use of Biologicals

There are currently no FDA approved biologicals to be injected into the joint at the time of surgery. The inclusion of biological and/or other non-FDA approved substances in the injectant will result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, amino acids, vitamins, and platelet rich plasma fall in this category.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
99999 Not Applicable
N/A

CPT/HCPCS Codes

Group 1

(14 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
Code Description
22548 Arthrd ant toral/xoral c1-c2
22551 Arthrd ant ntrbdy cervical
22552 Arthrd ant ntrbd cervical ea
22554 Arthrd ant ntrbd min dsc crv
22585 Arthrd ant ntrbd min dsc ea
22590 Arthrd pst tq craniocervical
22595 Arthrd pst tq atlas-axis
22600 Arthrd pst tq 1ntrspc crv
22614 Arthrd pst tq 1ntrspc ea add
22800 Arthrd pst dfrm<6 vrt sgm
22802 Arthrd pst dfrm 7-12 vrt sgm
22808 Arthrd ant dfrm 2-3 vrt sgm
22810 Arthrd ant dfrm 4-7 vrt sgm
22812 Arthrd ant dfrm 8+ vrt sgm
N/A

CPT/HCPCS Modifiers

Group 1

(4 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
GA WAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYER POLICY, INDIVIDUAL CASE
GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT
GZ ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE AND NECESSARY
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(22 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 22548, 22551, 22552, 22554, 22585, 22590, 22595, 22600, 22614, 22800, 22802, 22808, 22810, and 22812.

Group 1 Codes
Code Description
M46.31 Infection of intervertebral disc (pyogenic), occipito-atlanto-axial region
M46.32 Infection of intervertebral disc (pyogenic), cervical region
M46.33 Infection of intervertebral disc (pyogenic), cervicothoracic region
M48.01 Spinal stenosis, occipito-atlanto-axial region
M48.02 Spinal stenosis, cervical region
M48.03 Spinal stenosis, cervicothoracic region
M50.01 Cervical disc disorder with myelopathy, high cervical region
M50.021 Cervical disc disorder at C4-C5 level with myelopathy
M50.022 Cervical disc disorder at C5-C6 level with myelopathy
M50.023 Cervical disc disorder at C6-C7 level with myelopathy
M50.03 Cervical disc disorder with myelopathy, cervicothoracic region
M50.11 Cervical disc disorder with radiculopathy, high cervical region
M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region
M53.2X1 Spinal instabilities, occipito-atlanto-axial region
M53.2X2 Spinal instabilities, cervical region
M53.2X3 Spinal instabilities, cervicothoracic region
M54.11 Radiculopathy, occipito-atlanto-axial region
M54.12 Radiculopathy, cervical region
M54.13 Radiculopathy, cervicothoracic region
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
999x Not Applicable
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
99999 Not Applicable
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
DL39799 - Cervical Fusion
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Archived Date Status
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Keywords

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