CMS should keep recommended values for TLIF codes, orthopedic surgeon says

Spine

Morgan Lorio, MD, of Advanced Orthopedics in Altamonte Springs, Fla., said he is concerned about how CMS values spine surgery codes compared to suggestions from experts in the specialty.

Dr. Lorio, who is also chair of the Coding and Reimbursement Task Force and RUC adviser for the International Society for the Advancement of Spine Surgery, told Becker's how CMS should change its 2023 proposal to benefit spine and orthopedic surgeons.

Question: What's the biggest change you want to see from CMS' 2023 proposal?

Note: This response was edited for clarity and length.

Dr. Morgan Lorio: Currently, the U.S. physician reimbursement landscape is shaped by the interplay between both the CPT and the Relative Value Scale Update committee and CMS in the determination of physician payment, which is based on codes reported for work performed. The RUC is a little-known volunteer group consisting of a panel and medical society advisers. They provide highly expert, technical frontline input in order to balance CMS policies, so they are reflective of physician work, clinical staff time, supplies and equipment and professional liability. An accurate, high bar has long been established by RUC methodology in setting standards for the assessment and valuation of collected code survey data. The RUC process is currently the only structured venue through which physicians can contribute to their payment environment.

Reimbursement for spine procedures relies on CMS accepting and maintaining an RUC-passed value for specific spine CPT codes. In the 2023 Medicare physician fee schedule, CMS proposed updated values for a set of codes for complex TLIF (transforaminal lumbar interbody fusion) procedures. Their recommendations reject society and RUC input and instead propose lower reimbursement than appropriate for these challenging services.

Complex fusion TLIF codes such as CPT 26630 and 26633 may encompass an additional surgical decompression (CPT 63052) component in addition to the fusion-stabilization component. Historically, when either primary decompression or primary fusion is done separately, they are each reimbursed appropriately. Yet, when decompression is combined with TLIF fusion, for example, the 2023 Medicare physician fee schedule proposed rule suggests only a 92 percent reimbursement for the primary fusion and a further marginalized reimbursement for primary decompression of 75 percent.

These are the RUC approved work RVUs and those proposed by CMS in the proposed rule:

Code 22630
CMS proposed wRVU: 20.42
RUC recommended wRVU: 22.09

Code 22632
CMS proposed wRVU: 5.22
RUC recommended wRVU: 5.22

Code 22633
CMS proposed wRVU: 24.83
RUC recommended wRVU: 26.80

Code 22634
CMS proposed wRVU: 7.30
RUC recommended wRVU: 7.96

Code 63052
CMS proposed wRVU: 4.25
RUC recommended wRVU: 5.70

Code 63053
CMS proposed wRVU: 3.78
RUC recommended wRVU: 5.00

CMS recognized the TLIF code has been long undervalued. Yet, CMS has arbitrarily chosen to ignore both the added decompression work further while ignoring the RUC-passed values in general. The biggest change I would like to see from the CMS 2023 proposal is that CMS actually remunerate spine surgeons adequately. This can be accomplished by maintaining the RUC-passed value for the TLIF fusion code, as well as the RUC-approved RVUs for the additional decompression work when performed, thereby preserving the integrity of the RUC recommendation process.

 

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