Issue link: https://beckershealthcare.uberflip.com/i/627546
16 SPINE DEVICE & INNOVATION T wo-level cervical disc replacement went from a Category III CPT code to a Category I CPT code in January 2015. In addition, as more long-term data was published on one-level cervical disc replacement and demand continued to rise from surgeons, several insurers, including most of the Blue Cross Blue Shield plans began covering one-level cervical arthroplasty over the course of 2015. "It has been a year of really positive changes for spine ar- throplasty," says Kimberly Norton, vice president of healthcare policy and reimbursement at LDR Spine. "We are starting to see coverage grow for this technology and become more accepted in the community. I believe it will become the gold standard in the surgeon community as well as the payer community, especially with one-level arthroplasty." e North American Spine Society, International Society for the Advancement of Spine Surgeons and other professional organizations advocated for coverage and released coverage rec- ommendations for both one- and two-level spinal arthroplasty, paving the way for coverage. e inpatient DRG payment for cervical arthroplasty saw a 65 percent increase in 2015 over the previous year, adding to the momentum. "at signaled disc replacements are becoming more utilized and payers are starting to see the differential on what the procedure should be paid," says Ms. Norton. "Once it's used more in the outpatient setting, we'll see a similar move there." Not all payers reimburse for cervical disc replacement in the outpatient setting yet, even if they do for inpatient procedures. Payers typically base coverage policies and negotiations on Medicare's policies, but Medicare doesn't currently cover cer- vical disc replacement. e best patients for disc replacements are oen young patients — those with commercial insurance, workers compensation or personal injury. "Commercial payers look at the Medicare DRGs and apply their own conversion factors," says Ms. Norton. "As Medicare continues to look at the procedure, the outpatient setting opportunities will open up as they did with spinal fusion. ere are some surgeons who perform the procedure in the hospital outpatient setting or ASCs currently based on individually negotiated contracts, which shows it can be safely done." e literature proves one-level cervical disc arthroplasty achieves parity with spinal fusion in the outpatient setting. From a facility perspective, cervical disc arthroplasty is a well- paid procedure inpatient and outpatient. However, physicians are still paid more to perform anterior cervical discectomy and fusion. "Over time the payment differential between arthroplasty and ACDF will have parity," says Ms. Norton. e discectomy and instrumentation are both included in the arthroplasty code whereas the ACDF code pays the device and insertion separate- ly, accounting for the difference. However, medical societies and CMS have acknowledged the device and insertion will likely be bundled for spinal fusion codes in the future. "at might take a year or two, but we know with codes bundling for spine procedures we'll see the payments change." She also sees two-level cervical disc arthroplasty coverage expanding in the future, faster than the one-level procedures. Researchers don't need to re-establish the groundwork for cervical arthroplasty's effectiveness — that foundation already exists with the one-level procedures — and can focus on build- ing comparisons with fusion. "We have superiority claims five years out for the two-lev- el procedures," says Ms. Norton. "Instead of trying to figure out this new technology, the groundwork has been laid and I believe we'll see acceleration in coverage." ere are some payers, including United Healthcare and Medica in Minnesota with policies around two-level procedure coverage already. However, some payers report there isn't a high enough demand for coverage policies, so they don't develop them; at the same time, surgeons aren't performing two-level disc replacements because they can't obtain coverage. Key Thoughts on Cervical Disc Arthroplasty Coverage & Payer Policy By Laura Dyrda Spine, Orthopedic & Pain Management-Driven ASC Conference + The Future of Spine 124 Physicians Speaking, Primarily Spine Surgeons with 200+ Speakers and 117 Sessions 14 th Annual Swissotel Chicago June 9-11