Healthcare Economics
Enhanced Medicare Reimbursement
In appropriately selected patients, lumbar spine fusion procedures utilizing Carlsmed®’s aprevo® devices are covered by CMS and private payors. When used for inpatient lumbar spine fusion procedures, an additional reimbursement of up to $40,950 may be applied as a new technology add on payment (NTAP). Commercial payor reimbursement varies by contract.
It is important that your operative notes provide the following information:
- Document the use of aprevo®,
- Indicate ALL patient co-morbidities, and
- State the appropriate primary diagnosis code from the primary diagnosis code list or state the appropriate secondary diagnosis code from the secondary diagnosis code list.
To ensure Medicare beneficiaries have access to aprevo® in certain hospital outpatient procedures, the Centers for Medicare & Medicaid Services (CMS) also provides a Transitional Pass through (TPT) Payment. This means that both inpatient and certain outpatient procedures using aprevo® may be eligible for enhanced reimbursement.
Learn more about the positive news impacting aprevo® reimbursement.
Questions? Contact the Personalized aprevo® Coding Check (PaCC™) Hotline
866-277-3861
Diagnosis & Procedural Codes
Primary ICD-10-CM Diagnosis Codes
Secondary ICD-10-CM Diagnosis Codes
ICD-10-PCS Procedure Codes for Adult Spinal Surgery with aprevo® (X-codes)
Transitional Pass-Through Payment (TPT) CPT Codes
M40.00
Postural kyphosis, site unspecified
M41.54
Other secondary scoliosis, thoracic region
M40.04
Postural kyphosis, thoracic region
M41.55
Other secondary scoliosis, thoracolumbar region
M40.05
Postural kyphosis, thoracolumbar region
M4156
Other secondary scoliosis, lumbar region
M40.10
Other secondary kyphosis, site unspecified
M41.57
Other secondary scoliosis, lumbosacral region
M40.14
Other secondary kyphosis, thoracic region
M41.80
Other forms of scoliosis, site unspecified
M40.15
Other secondary kyphosis, thoracolumbar region
M41.84
Other forms of scoliosis, thoracic region
M40.204
Unspecified kyphosis, thoracic region
M41.85
Other forms of scoliosis, thoracolumbar region
M40.205
Unspecified kyphosis, thoracolumbar region
M41.86
Other forms of scoliosis, lumbar region
M40.209
Unspecified kyphosis, site unspecified
M41.87
Other forms of scoliosis, lumbosacral region
M40.294
Other kyphosis, thoracic region
M41.9
Scoliosis, unspecified
M40.295
Other kyphosis, thoracolumbar region
M43.8X4
Other specified deforming dorsopathies, thoracic region
M40.299
Other kyphosis, site unspecified
M43.8X5
Other specified deforming dorsopathies, thoracolumbar region
M40.30
Flatback syndrome, site unspecified
M43.8X6
Other specified deforming dorsopathies, lumbar region
M40.35
Flatback syndrome, thoracolumbar region
M43.8X7
Other specified deforming dorsopathies, lumbosacral region
M40.36
Flatback syndrome, lumbar region
M43.8X8
Other specified deforming dorsopathies, sacral and sacrococcygeal region
M40.37
Flatback syndrome, lumbosacral region
M43.8X9
Other specified deforming dorsopathies, site unspecified
M40.40
Postural lordosis, site unspecified
M43.9
Deforming dorsopathy, unspecified
M40.45
Postural lordosis, thoracolumbar region
M48.50XA
Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture
M40.46
Postural lordosis, lumbar region
M48.54XA
Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture
M40.47
Postural lordosis, lumbosacral region
M48.55XA
Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture
M40.50
Lordosis, unspecified, site unspecified
M48.56XA
Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture
M40.55
Lordosis, unspecified, thoracolumbar region
M48.57XA
Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture
M40.56
Lordosis, unspecified, lumbar region
M48.58XA
Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, initial encounter for fracture
M40.57
Lordosis, unspecified, lumbosacral region
M80.08XA
Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M41.20
Other idiopathic scoliosis, site unspecified
M80.88XA
Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M41.24
Other idiopathic scoliosis, thoracic region
M84.58XA
Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture
M41.25
Other idiopathic scoliosis, thoracolumbar region
M84.68XA
Pathological fracture in other disease, other site, initial encounter for fracture
M41.26
Other idiopathic scoliosis, lumbar region
M96.2
Postradiation kyphosis
M41.27
Other idiopathic scoliosis, lumbosacral region
M96.3
Postlaminectomy kyphosis
M41.30
Thoracogenic scoliosis, site unspecified
M96.4
Postsurgical lordosis
M41.34
Thoracogenic scoliosis, thoracic region
M96.5
Postradiation scoliosis
M41.35
Thoracogenic scoliosis, thoracolumbar region
Q67.5
Congenital deformity of spine
M41.40
Neuromuscular scoliosis, site unspecified
Q76.3
Congenital scoliosis due to congenital bony malformation
M41.44
Neuromuscular scoliosis, thoracic region
Q76.425
Congenital lordosis, thoracolumbar region
M41.45
Neuromuscular scoliosis, thoracolumbar region
Q76.426
Congenital lordosis, lumbar region
M41.46
Neuromuscular scoliosis, lumbar region
Q76.427
Congenital lordosis, lumbosacral region
M41.47
Neuromuscular scoliosis, lumbosacral region
Q76.428
Congenital lordosis, sacral and sacrococcygeal region
M41.50
Other secondary scoliosis, site unspecified
Q76.429
Congenital lordosis, unspecified region
M40.10
Other secondary kyphosis, site unspecified
M41.47
Neuromuscular scoliosis, lumbosacral region
M40.14
Other secondary kyphosis, thoracic region
M41.50
Other secondary scoliosis, site unspecified
M40.15
Other secondary kyphosis, thoracolumbar region
M41.54
Other secondary scoliosis, thoracic region
M41.40
Neuromuscular scoliosis, site unspecified
M41.55
Other secondary scoliosis, thoracolumbar region
M41.44
Neuromuscular scoliosis, thoracic region
M41.56
Other secondary scoliosis, lumbar region
M41.45
Neuromuscular scoliosis, thoracolumbar region
M41.57
Other secondary scoliosis, lumbosacral region
M41.46
Neuromuscular scoliosis, lumbar region
M43.8X9
Other specified deforming dorsopathies, site unspecified
The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) procedure codes are used by hospitals to report procedures performed in the hospital inpatient setting only. CMS established 12 new ICD-10-PCS procedure codes to identify surgeries for adult spinal deformity in which aprevo® is used. Cases involving the use of the aprevo® Intervertebral Body Fusion Device that are eligible for new technology add-on payments (NTAP) will be identified by any of the following ICD-10-PCS procedure codes:
XRGA0R7
Fusion of thoracolumbar vertebral joint using customizable interbody fusion device, open approach, new technology group 7
XRGA3R7 Same as above w. percutaneous approach
XRGA4R7 Same as above w. percutaneous endoscopic approach
XRGB0R7
Fusion of lumbar vertebral joint using customizable interbody fusion device, open approach, new technology group 7
XRGB3R7 Same as above w. percutaneous approach
XRGB4R7 Same as above w. percutaneous endoscopic approach
XRGC0R7
Fusion of 2 or more lumbar vertebral joints using customizable interbody fusion device, open approach, new technology group 7
XRGC3R7 Same as above w. percutaneous approach
XRGC4R7 Same as above w. percutaneous endoscopic approach
XRGD0R7
Fusion of 2 or more lumbar vertebral joints using customizable interbody fusion device, open approach, new technology group 7
XRGD3R7 Same as above w. percutaneous approach
XRGD4R7 Same as above w. percutaneous endoscopic approach
Transitional Pass-Through Payment (TPT) gives beneficiaries access to the advantages of new technologies by providing adequate payment for these new devices while Medicare collects the necessary cost data, which it will use for APC assignment in the future. Carlsmed’s aprevo® was granted a Transitional Pass-Through Payment as part of the quarterly update of the October 2021 Medicare Hospital Outpatient Prospective Payment System.
A Transitional Pass-Through Payment is intended to reimburse hospitals for the incremental cost of a device when the cost of the device exceeds the current device-related portion of the Ambulatory Payment Classification (APC) payment for the associated procedure.
Carlsmed’s aprevo® became eligible for Transitional Pass-Through Payment on October 1, 2021. The pass-through payment amount is based on the hospital’s charges for aprevo® and the individual hospital’s cost-to-charge ratio.
C1831 Personalized, cage (implantable)
The HCPCS supply item code developed specifically for aprevo® is C1831, Revenue Code 278, and should be reported on services involving CPT 22630 or 22633.
CPT Code
Description
22630
Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar
22633
Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace) other than for decompression), single interspace and segment, lumbar