Corpectomy Denial

Question:

We submitted an op note at the request of a payer (not Medicare) and they denied the corpectomy code we billed, 63081 with the fusion code, saying the documentation doesn’t support it.  Instead, they paid us for 22551. I don’t understand this because my neurosurgeon’s operative note says he did a corpectomy.

Answer:

Ah, but does the operative note specifically state he removed at least 50% of the cervical vertebral body – or that he did a total corpectomy – to justify using a corpectomy code. I suspect not which is why the payer “downcoded” 63081 and the fusion code to the anterior cervical decompression/discectomy and fusion code, 22551.

CPT guidelines specifically state that at least 50% of the cervical vertebral body must be removed to support using a corpectomy code. Recently, Cigna released guidance that says: “A targeted subset of cervical vertebral corpectomy claims billed with CPT codes 63081 and 63082, and where abuse is probable, will be pended. The operative report will then be reviewed before reimbursement to determine if the corpectomy criterion is met. If it is not met, the claim will be denied.”

The point is that the percentage of the vertebral body removed must be documented in the operative note to justify reporting a corpectomy code.

*This response is based on the best information available as of 04/27/17.