Statement on Coding Changes for Minimally Invasive SI Joint Fusion 2014

ISASS/IASP is fostering relationships with the payer community to keep them informed of guidelines that impact their members and policy decision making. ISASS/IASP continues to support access of medically necessary procedures to patients and support the spine practices of our member surgeons. The ISASS Statement on Coding Changes for Minimally Invasive SI Joint Fusion 2014 below is another example.

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Download Coverage Criteria in PDF Format »

March 31, 2014

TO: Over 60 Insurance Companies

RE: ISASS Statement on Coding Changes for Minimally Invasive SI Joint Fusion 2014

ISASS - International Society for the Advancement of Spine Surgery - is an international, scientific and educational society organized to discuss and assess existing strategies and innovative ideas in the clinical and basic sciences related to spine surgery and to enhance patient care.

ISASS supports decision-making at the physician-patient level based on medical necessity and achieving the best outcomes to address the patient’s medical condition. Medical necessity should not be determined by a mere administrative code reporting system such as CPT®. Prior to the July 1st 2013 implementation of the American Medical Associations (AMA’s) CPT Category III code 0334T, surgeons reported and were reimbursed for ALL sacroiliac joint fusion procedures when medically necessary, including minimally invasive, through the use of CPT code 27280.

The AMACPT Editorial Panel states “it is not reasonable to categorically deny payment for CPT Category III codes since they are effectively more specific, more functional versions of unlisted codes which many payers cover with appropriate documentation.” Additionally, the Panel says, “the assignment of a CPT Category III code to a service does not indicate that it is experimental or of limited utility, but only that the service or technology is new and is being tracked for data collection.”

While physicians are now required to adhere to an administrative coding change and report MIS SI joint fusions with a "new" CPT Category III code, the procedure has not changed, nor has the patient, the medical condition being treated, or the clinical resources associated with the procedure. ISASS believes that payers should make coverage decisions for a given procedure based on the clinical decision of the physician and the medical necessity presented by the patient, and NOT based on the CPT code required to report the work.

The (AMA)CPT Editorial Panel has now voted to establish a Category I CPT Code for MIS SI joint fusion.  The AMA officially announced the decision with a posting on their website on Wednesday, March 5:  http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-summary-panel-actions.page.  The new Category I CPT code will describe percutaneous/minimally invasive sacroiliac joint arthrodesis.

The Category I CPT code goes into effect January 1, 2015.  Until that time, the code associated with MIS SI joint fusion is still 0334T.  ISASS commends the recent AMA CPT Editorial Panel Category I review, refinement, and support for MIS SI joint fusion as a credible therapeutic modality with an appropriate Level of Evidence.  To that end, ISASS recommends that based upon the wide acceptance by the provider community throughout the United States and the uniformly positive current literature supporting use of the procedure, coverage of MIS SI joint fusion is justified and should be covered by your medical policy.

Attached is “Coverage Criteria” supporting the medical necessity of the procedure.

Thank you in advance for your consideration.  We are hopeful you will choose to revise your medical policy to include the above as medically necessary using the attached Coverage Criteria. 

Morgan P. Lorio, MD, FACS
Chair, ISASS Task Force/Coding & Reimbursement

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