    
 
February 10, 2020 
 
Seema Verma, MPH 
Administrator,  
Centers for Medicare & Medicaid Services 
Attention: CMS-1693-P 
P.O. Box 8016 
Baltimore, MD 21244-8016 
 
Submitted electronically via MedicarePhysicianFeeSchedule@cms.hhs.gov 
 
 
RE: Nomination of CPT 22867 as a Misvalued Code  
 


 
 
Dear Administrator Verma: 
 
The International Society for Advancement of Spine Surgery (ISASS), a multi-specialty association dedicated to the development and promotion of the must current surgical standards, as well as the highest quality, most cost-efficient, patient-centric, and proven cutting-edge technology for the diagnosis and treatment of spine and low back pain is writing to request that the Centers for Medicare & Medicaid Services (CMS) propose corrected values for this procedure in the proposed 2021 Medicare physician fee schedule rule (2021 Proposed Rule).  We set forth below our recommendations and rationale for establishing appropriate work and malpractice relative value units (RVUs) for spinal procedures reported with this code.  We also refer CMS to ISASS comments to the 2020 Medicare Physician Fee Schedule Proposed Rule (submitted September 27, 2019) where ISASS previously proposed nomination of CPT 22867 as potentially misvalued. 
 
Insertion of an interlaminar stabilization distraction device is described by the following code:  
 
CPT 22867  Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level   
 
We are nominating CPT 22867 as a potentially misvalued code because the current physician work and malpractice RVUs that CMS has assigned to CPT 22867 decompression/stabilization significantly undervalue this procedure.  Below we provide evidence to support: 
 
Increasing the work RVU value for CPT 22867 to 17.13, instead of 13.50, based on: 
 
 
 
 
 an anomalous relationship between this code and CPT 63047 Laminectomy with decompression, single vertebral segment, lumbar (15.37 RVU).  


 
 the addition of at least 4.0 work RVUs to represent the necessary insertion component of the procedure, based on the work values associated with CPT code 22868. 


 
 a crosswalk to an appropriate surgical comparator, CPT 67108, Repair of retinal detachment; with vitrectomy, to reflect the additional physician effort.    


 
 
Increasing the malpractice (MP) RVU value for CPT 22867 to at least 4.51, instead of 3.88, based on an anomalous relationship between this code and CPT 63047 and other similar spine procedures.  It would be more accurate, however, for CMS to provide an additional 1.18 MP RVUs  which reflects the MP RVUs in CPT 22868, which isolates the insertion procedure, for a total of 5.69 MP RVUs.   
 
We present compelling evidence below, including survey and retrospective study data validating our finding that CPT 22867 is misvalued, along with evidence that incorrect assumptions have been made in the valuation of the service.  This documentation underscores the necessity of CMS review of CPT 22867 as a potentially misvalued/undervalued code.  We recommend that CMS propose correcting the valuation in the 2021 Proposed Rule, rather than sending this code back to the RUC for resurvey, given the urgent need to rectify the significant rank order anomaly and preserve patient access to this procedure. 
 
I. CPT 22867 Work RVU is Misvalued  A. Reliable Data Demonstrate Increased Physician Work Time for CPT 22867 Compared to CPT 63047, Creating an Anomalous Relationship   





The Work RVU for CPT code 22867 is misvalued according to several standards established by CMS as well as the AMA RUC, as set forth below.  We recommend that CMS adopt a work value of 17.13 for CPT 22867, as detailed below.  
 
CPT 22867 laminectomy, decompression, stabilization procedure, always requires performance of an open decompression/laminectomy, and then the surgeon performs the additional work to implant the interspinous stabilization/device.  If an open decompression/laminectomy is not performed, CPT 22867 may not be reported according to CPT coding instructions.  Specifically, CPT coding instructions provide that insertion of an interlaminar/interspinous process stabilization/distraction device without open decompression or fusion is be reported with:   
 
CPT 22869, Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level; or  
 
 
 
 
 
CPT 22870, Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) 
 
 
Decompression/laminectomy is the inherent major component of the procedure described by CPT 22867.  If a surgeon performs a decompression/laminectomy as a stand-alone procedure, it is reported with the following CPT code: 
 
CPT 63047  Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar 
 
In fact, AMA CPT and payer billing instructions for the decompression/laminectomy with CPT 22867 confirm that the decompression/laminectomy (e.g., CPT 63047) may not be reported in addition to CPT 22867 (i.e., because it is already incorporated into CPT 22867).   
Thus while both CPT 22867 and CPT 63047 involve the common procedural steps of a laminectomy followed by an open decompression procedure, CPT 22867 also requires the surgeon to implant an interspinous stabilization/device.  It therefore should be impossible for CMS to assign lower work RVUs to CPT 22867 than CPT 63047, since it involves the same work as CPT 63047 plus the additional work involved with implanting the stabilization device.  In fact, the RUC has noted that CPT 22867 is more intense and complex than reference code 63047, especially with respect to technical skill required.1 
1 See February 2016 RUC Recommendations for CPT 2017.   
B. Physician Time/Effort Surveys Support Higher Work RVUs for CPT 22867 


 
The surgical steps involved in performing CPT 22867 and CPT 63047 are illustrated below: 
 
Steps 
 63047
 22867
 

Position patient 
 X 
 X 
 
Make midline incision in skin and subcutaneous tissue 
 X 
 X 
 
Expose L4 spinous process and lamina with subperiosteal dissection 
 X 
 X 
 
Remove the spinous process and lamina of L4 with a drill or bone-bitting instruments 
 X 
 X 
 
Remove the ligamentum flavum, exposing the thecal sac and nerve roots 
 X 
 X 
 


Steps 
 63047
 22867
 

Remove the medial L4-L5 facets with a drill or bone-biting instruments, exposing the L5 nerve roots 
 X 
 X 
 
Perform a foraminotomy for the L5 nerve root 
 X 
 X 
 
If a discectomy is necessary to complete the foraminotomy, it is performed 
 X 
 X 
 
Trials are used to define the appropriate implant size. The trial instrument is placed to evaluate proper contact with the spinous process and the amount of facet distraction. Bony resection of the spinous process may be needed to ensure proper contact of the implant 
  
 X 
 
Prior to insertion, the wings are opened slightly using the bending plier to ensure appropriate depth of insertion. 
  
 X 
 
The implant is introduced via impaction utilizing a mallet. 
  
 X 
 
Proper depth is determined if a ball tip probe can be passed freely leaving 12 mm separation from the dura. 
  
 X 
 
Once proper placement is achieved, the wings of the implant are securely crimped using the crimping plier 
  
 X 
 
In case of ligament reconstruction, the fascia and the supraspinous ligament are closed in one layer over the spinous processes. A surgical drain may be placed as per surgeons' preference. Paraspinal muscles are reattached to the supraspinous ligament.   
  
 X 
 
Skin is closed in the usual manner. 
 X 
 X 
 


 
Despite the additional physician work, for CY 2020, CMS assigned the following work RVUs to these two procedures:  
 
CPT 22867 laminectomy with implantation of interspinous device - 13.50 work RVUs, while  
 
CPT 63047 laminectomy without implantation of interspinous device - 15.37 work RVUs.    
 
 
 
This disparity has created a rank order anomaly between the two procedures, with the procedure involving less work having an approximately 14% higher work value than the procedure with the additional surgical steps.  This payment policy provides a serious impediment to physicians furnishing this higher-resource procedure, given that payment for CPT 22867 is reduced compared to CPT 63047 even though physicians perform additional work and have higher practice expenses. 
 
 
 
Two RUC surveys were conducted to assess the work RVUs for CPT 22867.  In addition, an independent physician work survey was conducted by RUC-experienced orthopaedic consultants in August 2018 to evaluate the appropriateness of the current work RVUs of 13.50 for CPT 22867.  The 2018 survey involved approximately 60 orthopedic and neurosurgeons who routinely perform CPT 22867 laminectomy, decompression, and insertion of stabilization device, and the specialty mix was evenly divided with 50% neurosurgeons and 50% orthopedic surgeons responding to the survey request.  Key takeaways from the survey include the following:  
 For both RUC surveys and the independent work survey, the surveyed surgeons modal response for a reference procedure was CPT code 63047  Laminectomy, facetectomy and foraminotomy , single vertebral segment; lumbar.  

 For each survey, the median response indicated that CPT 22867 is more intense and complex than CPT 63047.  The RUC acknowledged that CPT 22867 is more intense and complex than reference code 63047, especially with respect to technical skill required.2 

 The median work RVU was 18.00 to 20.00  far higher than the current 13.50 work RVUs. 


2 See February 2016 RUC Recommendations for CPT 2017.   
C. Retrospective Study Documents Higher Intraservice Time/Increased Work RVUs for CPT 22867 D. Incorrect Assumptions Made in Previous Valuation of CPT 22867   





 
For each of these surveys, the intraservice time for CPT 22867 was 90 minutes  the same as the intra-service time for CPT 63047. 
 
The comparative responses from the three CPT 22867 surveys are summarized below: 
 
CPT 22867 -- Physician Survey Results 
 
 Median
 

Description of service 
 RUC Survey July 2015  
 RUC Survey Nov 2015 
 Independent Survey  Aug 2018 
 
Pre-service evaluation face-to-face time prior to day of surgery 
 60  
 60  
 40  
 
Pre-service evaluation face to face time day of surgery 
 15  
 15  
 15  
 


Pre-service patient positioning time day of surgery 
 15 
 15 
 15  
 
Pre-service scrub, dress and wait time day of surgery 
 15 
 15 
 15  
 
Intra-service time 
 90 
 90 
 90  
 
Immediate post-service time 
 30 
 20 
 21  
 
Median Work RVU 
 20.00 
 18.00 
 20.00 
 
Median survey 25th percentile 
 17.00 
 16.47 
 18.28 
 
Most commonly chosen key reference service 
 63047 
 63047 
 63047 
 
Median number of post-op office visits 
 3 
 3 
 3 
 
Complexity/intensity relative to reference service, CPT 63047 
 Median response CPT 22867 is more intense & complex  
 Median response CPT 22867 is more intense & complex  
 Median response CPT 22867 is more intense & complex  
 
Median number of times performing procedure in the past 12 months 
 3 
 2 
 12.5 
 


 
In fact, the survey results support establishing work RVUs at 18.28 for CPT 22867.  This survey involved experienced surgeons that performed more procedures and thus the evaluation of the work is more reliable.   
 
 
A retrospective study examining hospital operating room data, including intraservice (procedural) time, for CPT code 22867 was completed in October 2018.   This study assessed total intraservice time, defined as incision to closure time.  Intraservice time did not include patient positioning or the physicians scrub and wait time.   
 
Hospital intraservice time was collected for 117 procedures at 5 different hospitals across the country. The data show a mean surgery/intraservice time of 121 minutes and a median intraservice time of 110 minutes. 
 
This data provides objective and reliable evidence that both the mean and median surgery times are significantly greater than the 90 minutes intraservice time included in all three of the physician work surveys  and greater than the intraservice time for CPT 63047.  This supports a significant increasing the work RVUs for CPT 22867 (as high as 18.0 RVUs) based on survey data of experienced surgeons. 
 
 
 
 
 
 
 
CPT 22867 has been undervalued since the code became effective January 1, 2017.  There is a long history of confusion surrounding CPT 22867 (lumbar decompression procedures with open decompression and stabilization) and a separate procedure, CPT 22869 (lumbar decompression without open decompression).  Misleading code descriptors generated confusion about the two procedures and negatively influenced the valuation of CPT 22867.   
 
CMS criteria indicate that incorrect assumptions made in the previous valuation of the service, such as a misleading vignette, survey, or flawed crosswalk assumptions in a previous evaluation support the nomination of a code as being potentially misvalued.   
 
The following is a brief overview of the coding/valuation history for CPT 22867; we request a meeting with CMS to discuss the details.  
 
 
2014 
 
The North American Spine Society (NASS) instructed surgeons to bill unlisted spine code CPT 22899 for the insertion of interlaminar stabilization distraction device procedure.  According to NASS, two Category III codes available at the time, 0171T and 0172T, were not the appropriate codes to use for the insertion of interlaminar distraction devices with open decompression.  These codes described the X-stop procedure, a somewhat similar spine procedure that notably does not involve an open decompression. 
 
NASS submitted an application for the 22867 laminectomy, decompression, stabilization distraction device procedure and codes were approved by the CPT Panel: 
 
22867  Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion  with open decompression, lumbar; single level   
 
22868  Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately) 
 
2015 
 
CPT codes 22867 and 22868 were surveyed for the first time in July 2015.  The RUC delayed these new codes, however, after learning that new CPT codes were approved for X-Stop  
In November 2015, CPT codes 22867 and 22868 laminectomy, decompression with stabilization and without stabilization were surveyed again, together with new CPT codes for X-Stop (CPT 22869 and add-on CPT 22870).   
 
 
 
 
2016 
 
CPT codes 22867 and 22868 and X-Stop codes were presented for valuation at the January 2016 RUC meeting, but the RUC and CMS confused the two procedures.  The parties erroneously indicated that two Category III codes for X-Stop were converted to two Category I CPT codes  CPT 22867 and 22869  even though CPT 22867 actually describes the laminectomy, decompression,  and insertion of stabilization distraction device procedure .  CPT 22867 was never assigned a Category III CPT code and could never be reported with the 22869 code.  
 
Combining the two surveys of two different procedures (22869 and 22867) clearly created confusion for all parties and resulted in erroneous statements about coding for these procedures  which we believe triggered the misevaluation of CPT code 22867. 
 
2017 
 
The RUC recommended that CMS adopt a work RVU of 15.00 for CPT code 22867 (temporarily designated at the time as 228X1), based on a crosswalk to CPT 29915, Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)  
 
However, CMS asserted that the RUC recommendation overestimated the work involved in furnishing this service  we believe because of the confusion between the two procedures.  
 
Instead, CMS crosswalked CPT 22867 to CPT 36832 (Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft), with a work RVU of 13.50.  CMS asserted that this is an accurate comparison because it has similar total time, work intensity, and number of visits.  However, the Journal of Vascular Surgery3 describes the procedure reported with CPT 36832 as a secondary procedure performed to maintain patency, excise an aneurysm or bypass a stenosis in an existing AV fistula.  We respectfully believe that this is not an accurate proxy for the work involved with CPT 22867 an open decompression/laminectomy with implantation of an interspinous stabilization device.  
3 Koksoy C, Brachiobasilic versus brachiocephalic arteriovenous fistula: A randomized prospective study.  J Vasc Surg 2009;49:271 available at https://www.jvascsurg.org/article/S0741-5214(08)02085-5/pdf.    
E. Add  Work RVUs for Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device F. Crosswalk CPT 22867 to CPT 67108 = 17.13 Work RVUs 





 
In the 2017 MPFS Final Rule, CMS stated:  We recognize that the RUC crosswalk of CPT code 29915 for CPT code 22867 has a total time that is more similar to the new code than the crosswalk we proposed (CPT code 36832).  Yet, CMS claimed CPT code 36832 is a more accurate comparison, because CPT code 36832 is similar in total time, work intensity and number of visits, had a higher service utilization, and was reviewed more recently.  
 
In fact, CMS argued that its crosswalk of CPT 36832 is supported by the ratio between total time and work in the key reference service, CPT code 63047 -- the very code we recommend that CMS use as a crosswalk.  
 
 
In short, CPT code 36832 fails to appropriately reflect the work based on the totality of the evidence.  Therefore, due to confusion regarding the two surveyed procedures, which ultimately led to incorrect and flawed crosswalk assumptions, we urge CMS to declare CPT 22867 as a misvalued code and revalue this code.  
 
 
As noted above, while both CPT 22867 and CPT 63047 involve the common procedural steps of a laminectomy followed by an open decompression procedure, CPT 22867 also requires the surgeon to implant the interspinous stabilization distraction device.  The work RVUs must reflect this additional surgical step.  The work value of the insertion procedure compared to a laminectomy can be approximated with the work value of CPT 22868, Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)  which is 4.0 work RVUs. 
   
We therefore recommend that CMS add  work RVUs in the range of 4.0 to CPT 22867 based on CPT code 22868.  
 
 
We believe CPT 671084 represents the best crosswalk to value CPT 22867 appropriately.  CPT 67108 was valued by the RUC and CMS in 2015 with 90 minutes intra-service time, which is equal to the survey time for 22867. In addition, both procedures are primarily outpatient with no inpatient visits and have similar total times (271 total minutes for CPT 22867 and 295 for CPT 67108). These similarities make CPT 67108 a more appropriate crosswalk for 22867 than the CMS referenced crosswalk code of CPT 36832.    
4 CPT 67108, Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique. 
 
CPT 67108 is valued at 17.13 work RVUs.  This is less than the combined work values of CPT 63047 (15.37) plus CPT 22868 (4.0) and the survey data presented above, and slightly less than the combined values of CPT 22868 (currently 13.50) plus CPT 22868 (4.0).   
 
We therefore recommend that CMS propose adoption of 17.13 work RVUs for CPT 22867 in the proposed 2021 Medicare physician fee schedule rule.   
 
 
 
 
 
 
 
 
II. CPT 22867 Malpractice RVU is Misvalued  A. Increase MP RVUs to at least 4.51 for CPT 22867   





 
 
ISASS recommends that CMS increase the MP RVUs for CPT 22867 from 3.88 in 2020 to at least 4.51.  This would align the MP RVUs for CPT 22867 with CPT 63047 and other similar spine procedures in terms of specialty-level and service-level risk factors as well as intensity and complexity of the service.  
 
In the final 2020 PFS rule, CMS reduced the MP RVUs for CPT 22867 from 3.97 to 3.88.  We understand that CMS views the MP RVUs for CPT code 22867 to be the result of recent malpractice premium data and the current specialty mix that furnishes these services.  However, the specialty mix for CPT codes 22867 and CPT 63047 are identical. Thus, the two values should be similar.  
 
Furthermore, it is important to note that the laminectomy and decompression portion of the procedure included in CPT 22867 and CPT 63047 are the same.  The only difference is that CPT 22867 involves the additional work involved with implanting the motion preserving interlaminar/interspinous stabilization device which, in turn, results in additional work of implanting an implant that should increase the malpractice RVUs.  Thus, there is no logical reason why the malpractice RVUs for CPT 22867 should be lower than that of CPT 63047.  We believe that correction of the work RVUs for 22867 to reflect the intensity/complexity of this procedure, as recommended above, would provide additional support for revising the malpractice RVU for CPT 22867.  
 
We therefore request that the CMS correct the MP RVUs for CPT 22867 in the proposed 2021 PFS rule.  We believe that the level of at least 4.51 is most appropriate given the similarities to CPT 63047.  It would be more accurate, however, for CMS to provide an additional 1.18 MP RVUs  which reflects the MP RVUs in CPT 22868, which isolates the insertion procedure, for a total of 5.69 MP RVUs.     
 
* * * 
 
In summary, we request that CMS consider CPT 22867 as a potentially misvalued code for 2021 because the current physician work and malpractice RVUs that CMS has assigned to CPT 22867 significantly undervalue this procedure.  We will be contacting your staff separately to request a meeting to discuss resolution of this important issue.  In the meantime, please let me know if you have any questions or if you need additional information.    
 
 
 
 
 
 
 
____________________________________________________________________________ 
 
Thank you for your time and consideration of ISASSs comments. We greatly appreciate the  
opportunity to participate in efforts to more efficiently and accurately capture current care delivery. We commend CMS on its continued efforts to improve care quality and access. If you have any questions on our comments, please do not hesitate to contact Morgan Lorio, MD, Chair ISASS Coding and Reimbursement Taskforce at mloriomd@gmail.com.   
 
 
Sincerely, 
 
 

Morgan Lorio, MD, FACS 
Chair, ISASS Coding and Reimbursement Taskforce  
 

