Billing and Coding: Cervical Fusion

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.](https://www.cms.gov/medicare/national-correct-coding-
initiative-edits/ncci-policy-manual-medicare)

### 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  
  
---|---  
  
GA

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

****

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. 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.
  3. 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.

  4. 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)](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/bp102c16.pdf). Amniotic and placenta
derived injectants, amino acids, vitamins, and platelet rich plasma fall in
this category.