DRAFT LCD Reference Article Billing and Coding Article

Billing and Coding: Cervical Fusion

DA59608

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
CGS Administrators, LLC	MAC - Part A	15101 - MAC A	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part B	15102 - MAC B	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part A	15201 - MAC A	J - 15	Ohio
CGS Administrators, LLC	MAC - Part B	15202 - MAC B	J - 15	Ohio

Draft Article Information

General Information

Source Article ID
A59608

Draft Article ID
DA59608

Draft Article Title
Billing and Coding: Cervical Fusion

Article Type
Billing and Coding

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.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

Refer to the draft Local Coverage Determination (LCD) DL39738 Cervical Fusion for reasonable and necessary requirements and frequency limitations.

The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.

Coding Guidance

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

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.

This policy 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).

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.

If you want to list out the modifiers for known non-covered service you could bullet that out under the notice section.

Modifier

When to Use Modifier

Waiver of Liability Statement

Issued as Required by Payer

Policy, Individual Case

Report when you issue a mandatory ABN for a service as required and keep it on file. You don’t need to submit a copy of the ABN, but you must make it available on request. Use

the –GA modifier when both covered and non-covered services appear on an ABN-related claim.

–GX

Notice of Liability Issued,

Voluntary Under Payer Policy

Report when you issue a voluntary ABN for a service we never cover because it’s statutorily excluded or isn’t a Medicare

benefit. Use this modifier combined with modifier –GY.

–GY

Notice of Liability Not Issued,

Not Required Under Payer

Policy

Report Medicare statutorily excludes the item or service, or the item or service doesn’t meet the definition of a Medicare

benefit. Use this modifier combined with modifier –GX

–GZ

Expect Item or Service

Denied as Not Reasonable

and Necessary

Report when you expect we’ll deny payment of the item or service because it’s medically unnecessary and you didn’t

issue an ABN.

Documentation Requirements

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
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.
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.

The operative note should include the procedure performed and any associated/additional procedures performed at the same time.

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.)
- 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 Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, amino acids, vitamins, and platelet rich plasma fall in this category.

Response To Comments

Number	Comment	Response
1

Coding Information

Bill Type Codes

Code	Description
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Revenue Codes

Code	Description
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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

(21 Codes)

Group 1 Paragraph

N/A

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
M54.11	Radiculopathy, occipito-atlanto-axial region
M54.12	Radiculopathy, cervical region
M54.13	Radiculopathy, cervicothoracic region

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

N/A

ICD-10-PCS Codes

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
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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
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Other Coding Information

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

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

N/A

Associated Documents

Related Local Coverage Documents
LCDs
DL39741 - Cervical Fusion

Updated On	Archived Date	Status
01/08/2024	N/A	N/A	You are here

Keywords

N/A

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Billing and Coding: Cervical Fusion

Document Note

Note History

Contractor Information

Draft Article Information

General Information

CMS National Coverage Policy

Article Guidance

Coding Guidance

Documentation Requirements

Use of Biologicals

Response To Comments

Coding Information

Bill Type Codes

Please accept the License to see the codes.

Revenue Codes

Please accept the License to see the codes.

CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

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

Group 1

ICD-10-PCS Codes

Group 1

Additional ICD-10 Information

Bill Type Codes

Please accept the License to see the codes.

Revenue Codes

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Other Coding Information

Group 1

Coding Table Information

Revision History Information

Associated Documents

Keywords

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