Reimbursement FAQs

Where can I find the Medicare Physician Fee Schedule?

The CMS website provides a Physician Fee Schedule Look-Up Tool for your convenience.

What CPT code can be reported for a traditional ACDF (anterior cervical discectomy and fusion) procedure?

CPT 22551 is described as “Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2” per the official AMA/CPT codebook. CPT is a trademark of the AMA.

What CPT code can be reported when an allograft ring is used in an ACDF procedure?

CPT 20931 is described as “Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)” per the official AMA/CPT codebook. CPT is a trademark of the AMA.

What CPT code can be reported when I-FACTOR is used in an ACDF procedure?

CPT 20930 is described as “Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)” per the official AMA/CPT codebook.

What are NCCI edits?

The National Correct Coding Initiative (NCCI) was implemented by Medicare to provide code pair edits to prevent improper payment when certain codes are submitted together for Medicare Part-B services. This information can be accessed on the CMS website at NCCI Edits

Can an ACDF procedure be performed in the Ambulatory Surgery Center (ASC) setting of care?

Medicare and many commercial insurers now allow this procedure to be performed in the ASC. Specific Health Plan and carrier guidelines should always be followed when determining the appropriate setting of care for any procedure.

What are some of the HCPCS code options available for an ACDF procedure and the use of I-FACTOR?

HCPCS code assignment is dependent on many factors and is determined by the provider and the specific Health Plan guidelines. Some possible options include the following:

HCPCS Coding Pathway Options
HCPCS Code[1] HCPCS Code Description
C1713 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
L8699 Prosthetic implant, not otherwise specified
C9399 Unclassified drugs or biologicals
C1889 Implantable/insertable device for device intensive procedure, not otherwise classified

Many Health Plans require pre-authorization for spinal procedures. Are there general guidelines for how long this process can take?

Each insurance company, each plan and each specific case will have a defined process and timeline based on carrier guidelines and state regulations for pre-authorization of a spine procedure such as ACDF if required. It is very important to review and following the individual guidelines that are applicable to the case. The following summary gives an overview of the possible timelines for pre-authorization and pre-authorization denial appeals. This is only a generalized example and does not represent any specific insurance plan guidelines.

Pre-Authorization Process Generalized Overview Estimated Time Frames
Initial Pre-Authorization 1-15 Days
Peer to Peer Reconsideration 1-3 Days
1st Level Appeal 3-30 Days
2nd Level Appeal 3-30 days
External Appeal (IRO) 5-45 Days

Who can I contact for additional reimbursement questions and support services?

Contact the Cerapedics Reimbursement Support Program at 800-361-0795 or Cerapedics@MCRA.com

[1] 2018 HCPCS, www.cms.gov