procedure code and description
22851 – Apply spine prosth device – average fee payment – $480 – $490
22840 Posterior non-segmental instrumentation (e.g. harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation) (list separately in addition to code for primary procedure)
22842 Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminal wires); 3 to 6 vertebral segments (list
separately in addition to code for primary procedure)
22845 Anterior instrumentation; 2 to 3 vertebral segments (list separately in addition to code for primary procedure)
22854 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
22859 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
Procedure CODE 22856: Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical.
* Do not report code in conjunction with 22554, 22845, 22851, 63075, 0375T when performed at the same level.
* Do not report 22856 in conjunction with 69990.
* For additional interspace cervical total disc arthroplasty, see 22858, 0357T
Interspinous Process Decompression (IPD® ) [X STOP® and coflex ® Interlaminar Technology (CPT Codes 0171T and 0172T)]
(Note: May also see IPD requested inappropriately as spinal fixation; CPT codes 22842, 22843, 22844, and 22849.)
Introduction
Back pain is a common symptom and , for some, can lead to disability . Devices that keep specific areas of the spine rigid are known as interspinous fixation devices. Surgeons attach these devices to the bones of the spine (vertebrae) to prevent the joints from bending and twisting as they normally would. The intent of the devices is to decrease pain. These devices are typically used as part of fusion surgery. The device holds the spine in place while the implanted bone material eventually fuses the vertebrae together . Occasionally the device might be used without fusion surgery in order to relieve pres sure on the spinal cord or nerve. Interspinous fixation devices are considered unproven. There is not enough evidence to show whether these devices are effective when used during a fusion surgery or on their own. The health plan considers these devices investigational.
INDICATIONS FOR COVERAGE
1. Preauthorization by the Plan is required;
2. IPD® is considered medically reasonable and necessary for patients who meet ALL of the following criteria:
a. Age 50 or older suffering from intermittent neurogenic claudication secondary to a confirmed (eg. MRI or CT scan) diagnosis of lumbar spinal stenosis;
AND
b. Members with moderately impaired physical function who experience relief from their symptoms of leg/buttock/groin pain (with or without back
pain) in flexion;
AND
c. Have undergone at least six (6) months of non operative conservative treatment including non-steroidal therapy, a series of epidural injections, and physical therapy exercises to help stabilize the spin and help to build endurance and increase flexibility.
3. IPD® may be implanted at 1 or 2 lumbar levels, but at no more than 2 levels.
WHEN COVERAGE WILL NOT BE APPROVED
IPD® will not be considered medically reasonable and necessary with ANY of the following conditions:
1. Allergy to titanium or titanium alloy;
2. Spinal anatomy or disease that would prevent implant of the device or cause the device to be unstable in situ, such as significant instability of the lumbar
spine, e.g., isthmic spondylolisthesis or degenerative spondylolisthesis greater than grade 1.0 (on a scale of 1 to 4); an ankylosed segment at the affected
level(s); acute fracture of the spinous process or pars interarticularis;
3. Significant scoliosis (Cobb angle greater than 25 degrees);
4. Cauda equina syndrome defined as neural compression causing neurogenic bowel or bladder dysfunction;
5. Active systemic infection or infection localized at the site of implantation;
6. Diagnosis of severe osteoporosis..
SPECIAL NOTES
It is expected that the members have not previously received a laminotomy or laminectomy at the same level of the spine as the IPD®.Services performed on members who have received another spinal procedure such as any spinal instrumentation (CPT codes 22840-22849) and laminectomy or laminotomy (CPT codes 63001-63048) may be subject to denial and will be reviewed by the medical director on an individual case basis. If inpatient level of care is requested for this procedure, the request will need to be reviewed by the Medical Director for medical necessity.
Cages used in Spine Surgery
Use code 22851 for Synthetic (sometimes referred to as PEEK) Cages implanted during Fusion procedures. Per CPT Assistant guidance, the 22851 code for cages is only to be billed once per spinal interspace area. Thus, if the physician inserts 2 cages at level L3-4 and 1 cage at level L4- 5, bill the code twice (codes 22851 and 22851-59) for the case (do not bill the 22851 code 3 times because 3 cages were used). Usually codes 20936 or 20937 are used for Morcellized Autograft being used to fill in around the cages. Bill the implant supply with code L8699.
Billing Guideline from UHC
Payment for 22867, 22868, 22869 and 22870 will be an inclusive payment. No additional codes for approach or hardware placement should be billed or paid. Utilization Guidelines
** It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. This procedure may be performed at one or two spinal levels. When services are performed in excess of established parameters, they may be subject to review for medical necessity.
** It is expected that the patient has not previously received a laminotomy or laminectomy at the same level of the spine as the IPD.
** Services performed on patients who have received another spinal procedure such as any spinal instrumentation (CPT codes 22840-22849) and laminectomy or laminotomy (CPT codes 63001-63048) may be subject to denial. Documentation Requirements
** The medical record must contain documentation that fully supports the medical necessity of the procedure performed. This documentation includes, but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures and the medical records must be available request.
** Documentation must include evidence of six months of non operative treatment. Examples of non operative treatment include medications, corticosteroid injection therapy, rest or restricted activity, devices designed to help stabilize the spine such as back braces/corsets, and physical therapy/exercises to help stabilize the spine, that help to build endurance and increase flexibility.
** The diagnosis of lumbar stenosis must be confirmed by radiological evidence i.e. a report resulting from a CT scan, MRI, or a myelogram.
X STOP® Interspinous Process Decompression System (“X STOP”):
A titanium implant that fits between the spinous processes of the lower (lumbar) spine. It is made from titanium alloy and consists of two components: a spacer assembly and a wing assembly. FDA Approval Information for X STOP® Interspinous Process Decompression System ; available at http://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearan ces/recently-approveddevices/ucm078378.htm. (Accessed October 29, 2015)
coflex ® Interlaminar Technology: A U-shaped, titanium alloy implant that fits between two bones called the spinous processes located in the lower back (lumbar region) of the spine. The device is placed between two adjacent lower back bones after surgical relief of pressure on the spinal cord and nerves (decompression) to ease the pain associated with lumbar spinal stenosis, a narrowing of the passages for the spinal cord and nerves. FDA Approval Information for coflex ®
Interlaminar Technology; available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm327502.htm.
Interspinous Process Decompression (IPD® ) [X STOP® and coflex ® Interlaminar Technology (CPT Codes 0171T and 0172T)]
(Note: May also see IPD requested inappropriately as spinal fixation; CPT codes 22842, 22843, 22844, and 22849.)
X STOP® Interspinous Process Decompression System (“X STOP”): A titanium implant that fits between the spinous processes of the lower (lumbar) spine. It is made from titanium alloy and consists of two components: a spacer assembly and a wing assembly. FDA Approval Information for X STOP® Interspinous Process Decompression System ;
coflex ® Interlaminar Technology: A U-shaped, titanium alloy implant that fits between two bones called the spinous processes located in the lower back (lumbar region) of the spine. The device is placed between two adjacent lower back bones after surgical relief of pressure on the spinal cord and nerves (decompression) to ease the pain associated with lumbar spinal stenosis, a narrowing of the passages for the spinal cord and nerves. FDA Approval Information for coflex ® Interlaminar Technology;
Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (list separately in addition to code for primary procedure)
DESCRIPTION
Interspinous fixation (fusion) devices are being developed to aid in the stabilization of the spine. They are being evaluated as alternatives to pedicle screw and rod constructs in combination with interbody fusion. Interspinous fixation devices are also being evaluated for stand-alone use in patients with spinal stenosis and/or spondylolisthesis.
Background
Contemporary models of interspinous fixation devices have evolved from spinous process wiring with bone blocks and early device designs (e.g., Wilson plate, Meurig-Williams system, Daab plate). The newer devices range from paired plates with teeth to U-shaped devices with wings that are attached to the spinous process. They are intended to be an alternative to pedicle screw and rod constructs to aid in the stabilization of the spine with interbody fusion. Interspinous fixation devices are placed under direct visualization, while screw and rod systems may be placed either under direct visualization or percutaneously. Use of an interspinous fixation device in combination with a unilateral pedicle screw system has also been proposed. Interspinous fixation devices are not intended for stand-alone use.
Interspinous fixation (fusion) devices contrast with interspinous distraction devices (spacers), which are used alone for decompression and are typically not fixed to the spinous process. In addition, whereas interspinous distraction devices may use dynamic stabilization, interspinous fixation devices are rigid. However, the fixation devices might also be used to distract the spinous processes and decrease lordosis. Thus, the fixation devices might be used off-label without interbody fusion as decompression (distraction) devices in patients with spinal stenosis. If fixation devices are used alone as a spacer, there is a risk of spinous process fracture.
For use in combination with fusion, it is proposed that interspinous fixation systems are less invasive and present fewer risks than pedicle or facet screws. However, while biomechanical studies indicate that interspinous fixation devices may be similar to pedicle screw-rod constructs in limiting the range of flexion-extension, they may be less effective than bilateral pedicle screw-rod fixation for limiting axial rotation and lateral bending.1 There is a potential for a negative impact on the interbody cage and bone graft due to focal kyphosis resulting from the interspinous device. There is also a potential for spinous process fracture. Given these uncertainties, studies are needed that compare health outcomes between interspinous fixation devices and pedicle screw-rod fixation.
Regulatory Status
The following interspinous fixation devices have received clearance to market by the U.S. Food and Drug Administration (FDA). This may not be an exhaustive list.
• Affix™ (NuVasive)
• Aileron™ (Life Spine)
• Aspen™ (Lanx, acquired by BioMet)
• Axle™ (X-Spine)
• BridgePoint™ (Alphatec Spine)
• coflex-F® (Paradigm Spine)
• Inspan™ (Spine Frontier)
• Interbridge Interspinous Posterior Fixation System (LDR Spine)
• Minuteman™ (Spinal Simplicity)
• PrimaLOK™ (OsteoMed)
• Octave™ (Life Spine)
• Spire™ (Medtronic)
• SP-Fix™ (Globus)
• Zip Mis Interspinous Fusion System
Interspinous fixation devices are intended to be used as an adjunct to interbody fusion. For example, the indication for use of the coflex-F implant:
“is a posterior, nonpedicle supplemental fixation device intended for use with an interbody cage as an adjunct to fusion at a single level in the lumbar spine (L1-S1). It is intended for attachment to the spinous processes for the purpose of achieving stabilization to promote fusion in patients with degenerative disc disease – defined as back pain of discogenic origin with degeneration of the disc confirmed by history and radiographic studies – with up to Grade 1 spondylolisthesis.”
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