Cervical Fusion with Disc Removal Hospital Outpatient Department Required Documentation

Cervical disc removal is a surgical procedure that may relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. The procedure is accompanied by a fusion surgery to stabilize the spine.

Typically, there is an anterior approach to reach damaged vertebrae. An incision is made through the front of the neck, careful to avoid the esophagus, trachea, and thyroid. Retractors separate the intravertebral muscles. The disc space is cleaned out, removing the cartilaginous material above and below the vertebrae to be fused. The physician obtains and packs separately reportable graft material of iliac or other donor bone into the spaces. Traction is decreased to maintain the graft in its bed. The fascia is sutured, a drain is placed, and the incision is sutured. 

Coverage
Effective for dates of service July 1, 2021, and after, hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for cervical fusion with disc removal if performed in a HOPD setting and billed with the following CPT® codes.

Documentation Requirements

Decompression of symptomatic cervical nerve root impingement documentation requirements includes:

• Persistent or recurrent moderate to severe arm pain present for a minimum of 12 weeks within the current episode of neck pain with failure to respond to multimodal conservative management
   
• Nerve compression negatively impacts activities of daily living (ADLs)
   
• Other sources of pain have been excluded
   
• Imaging (MRI or CT) present and supports central, lateral recess or foraminal stenosis with signs and symptoms with one of the following:
   
  • Cervical degenerative disc disease as indicated by the presence of 1 or more of the following findings: herniated nucleus pulposus, narrowing of the intervertebral disc, disc osteophytes, facet hypertrophy, or synovial cysts
  • Tumors (primary or metastatic) 
  • Post-infection radiographic findings 
  • Spinal instability as defined by subluxation or translation more than 3.5 mm on static lateral views or dynamic radiographs OR sagittal plane angulation of more than 11 degrees between adjacent segments

Decompression of symptomatic cervical canal stenosis required documentation includes:

• Persistent or recurrent moderate to severe arm pain present for a minimum of 12 weeks within the current episode of neck pain with failure to respond to multimodal conservative management or nerve compression negatively impacts ADLs or spastic gait, loss of manual dexterity, problems with sphincter control
   
• Support that all other sources of pain/neurological deficits have been excluded
   
• Imaging (MRI or CT) present and supports evidence of central stenosis at the corresponding level with clinical signs and symptoms AND include one of the following:
   
  • Cervical degenerative disc disease as indicated by the presence of 1 or more of the following findings: herniated nucleus pulposus, narrowing of the intervertebral disc, disc osteophytes, facet hypertrophy, and/or synovial cysts
  • Congenital short pedicles
  • Tumors: primary or metastatic 
  • Post-infection imaging findings 
  • Ossification of the posterior longitudinal ligament 
  • Spinal instability as defined by subluxation or translation more than 3.5 mm on static lateral views and/or dynamic radiographs OR sagittal plane angulation of more than 11 degrees between adjacent segments
  • Cord compression with or without increased cord signal 

Documentation to support cervical fusion surgery is being requested for the decompression or stabilization of the cervical spine should include: 

• Traumatic injuries including fractures, dislocations, fracture-dislocations, or traumatic ligamentous disruption
   
• Spinal tumors involving the spine or spinal canal 
   
• Infection involving the spine in the form of discitis, osteomyelitis, or epidural abscess 
   
• Deformities that include the cervical spine 
   
• Other cervical indication

Additionally, include documentation to support substantial functional limitation (severe neck pain, difficulty ambulating, decreased ability to perform ADLs etc.) OR progression of deformity.

Resources

• OPD Operational Guide  (PDF)
• OPD FAQ (PDF)
• Cervical Fusion 
• Cervical Fusion Checklists
  • Jurisdiction J Part A — Cervical Fusion with Disc Removal Checklist
  • Jurisdiction M Part A — Cervical Fusion with Disc Removal Checklist