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Understanding Medicare Complexity Adjustment Payment for Spine Procedures

By Paul Cadorette, CPC, COC, CPC-P, COSC, CASCC, Director of Education, nimble solutions

Watch the 2023 Anatomy of Coding Other Spine Procedures coding course on demand. Register here.

Our upcoming webinar focuses on the coding intricacies of spinal procedures – a category encompassing diverse services beyond arthrodesis coding. This range includes interventions like vertebroplasties, vertebral augmentation, total disc arthroplasty, and spinous process distraction devices, among others.  

These procedures can fall outside the realm of standard ASC coding. In this blog post, I’ll discuss how to utilize the Medicare Complexity Adjustment program for add-on codes for other spine procedures.  

Medicare Complexity Adjustment for Spine Procedure

There are several challenges to coding spine procedures, especially when multiple procedures were performed on one patient.  

One compelling aspect of the Medicare Complexity Adjustment is its impact on reimbursements associated with add-on codes. Unlike typical scenarios where add-on codes are considered packaged services with no additional payment, this program introduces a novel approach. Instead of isolating the add-on code, it groups the primary CPT code together with its corresponding add-on code for specific services, allowing eligible ASCs to receive extra reimbursement. 

How Does Medicare Complexity Adjustment Work? 

The Centers for Medicare and Medicaid Services (CMS) introduced 55 HCPCS “C” codes (C7500-C7555) designed for reporting these services.  
By employing these codes in combination with the appropriate HCPCS “C” code, ASCs can unlock the potential for supplementary reimbursement. 

For instance, let’s consider the case of a 2-level cervicothoracic vertebroplasty. In the standard scenario, billing CPT codes 22510 and +22512 would result in payment for 22510 ($1415) only.  
However, under the Medicare Complexity Adjustment, billing HCPCS code C7504, which represents the combination of CPT codes 22510 and +22512, yields an anticipated reimbursement of $3138 – a substantial difference.

Navigating Vertebral Augmentation Procedures

The concept of the Medicare Complexity Adjustment also extends to vertebral augmentation procedures. For cervical spinal region interventions, where no designated CPT codes exist, Unlisted spine code 22899 comes into play. This provides a framework for accurately reporting such procedures. 

For instance, a 2-level thoracic vertebral augmentation (22513/+22515) could potentially bring in a reimbursement of $3138, whereas utilizing HCPCS code C7507 could lead to an impressive reimbursement of $6434. 

Similarly, a 2-level lumbar vertebral augmentation (22514/+22515) is associated with a potential reimbursement of $3138, while employing HCPCS code C7508 could open the doors to a significant reimbursement of $6434. 

Pro Tip: Reporting HCPCS Codes

To maximize the benefits of the Medicare Complexity Adjustment, it’s crucial to report the appropriate HCPCS code based on the first level treated. This strategic approach ensures accurate representation of the procedure and the associated reimbursement. 

For instance, the HCPCS code description for C7505 specifies “Percutaneous vertebroplasties, first lumbosacral and any additional cervicothoracic or lumbosacral vertebral bodies.” This indicates that when the first vertebral body treated is L1 and the second vertebral body treated is T12, reporting C7505 is appropriate. 

Conversely, if the first vertebral body treated is T12 and the second is L1, reporting C7504 aligns with the first cervicothoracic vertebral body, encompassing any additional lumbosacral vertebral bodies. 

Capitalizing on Opportunities for Maximizing Reimbursement 

As healthcare professionals, it’s our responsibility to ensure we leverage every opportunity to optimize reimbursements for the services we provide. Incorporating the Medicare Complexity Adjustment into your ASC’s coding and billing practices can have a profound impact on overall revenue.  

This blog post outlines some of the topics covered in the 2023 Other Spine Procedures coding course, available on demand with corresponding AAPC continuing education units included.

For further insights into the realm of spine coding and reimbursement, watch our on-demand webinar, Master 2024 Spine Code Challenges.