22558
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
22.94
Facility
$1423.88
Non-Facility
$1423.88
Documentation Required
- This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37848 for Lumbar Spinal Fusion; refer to LCD L37848 for clinical medical necessity criteria.
- Medical record must document that the patient met at least one of the lumbar fusion indications prior to surgery.
- For elective procedures, record must verify that the qualified surgeon, operating room, and all necessary equipment and hardware were available prior to induction of anesthesia.
- When fusing >1 level for instability, the record must show that each fused level is affected by one of the listed instability causes.
Key Coverage Criteria
- Radiographic or clinical evidence of lumbar spinal instability due to congenital deformity, trauma, fracture, chronic degenerative condition, tumor, infection, erosive condition, space-occupying lesion, or iatrogenic causes.
- Symptomatic spinal deformity (without instability or neural compression) with functional limitation in daily activities from back pain, nonresponse to ≥1 year of non-operative treatment, and at least one of: sagittal or coronal imbalance ≥5 cm on full-spine radiograph, progression of deformity ≥10 degrees, or scoliotic curvature >30 degrees.
- Revision lumbar fusion for pseudarthrosis after prior spine surgery when all are met: initial postoperative period of reduced pain, ≥1 year since prior surgery, clear radiographic evidence of pseudarthrosis, and exhaustion of available conservative treatments.
- Symptomatic compression of neural elements from disc pathology requiring disc excision for decompression at the fused level(s).
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: IOM is performed by either a licensed physician trained in clinical neurophysiology (e.g., a neurologist, physiatrist) or a trained technologist who is practicing within the scope of his/her state license /certification as defined by state law or appropriate authorities and is working under the direct supervision of a physician trained in neurophysiology and i [...]
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: IOM is interpreted by a licensed physician trained in clinical neurophysiology, other than the operating surgeon or anesthesiologist, who is either physically in attendance in the operating suite or present by means of a real-time remote mechanism for all electroneurodiagnostic (END) monitoring situations and is immediately available to interpret the recording [...]
3 Active Policies
A56396 — Billing and Coding: Lumbar Spinal Fusion
L37848 — Lumbar Spinal Fusion
CIGNA-0509 — Intraoperative Monitoring - (0509)
Related Codes
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