John T. Smith, MD Jessica V. Morgan John A. Heflin, MD

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Presentation transcript:

John T. Smith, MD Jessica V. Morgan John A. Heflin, MD Comparison of Billing Practices and Reimbursement Associated with Rib-Based Growing Constructs and Magnetically Controlled Growing Rod Procedures. John T. Smith, MD Jessica V. Morgan John A. Heflin, MD John.smith@hsc.utah.edu

Disclosures Smith: Consultant: DepuySynthes, Globus, Biomet, Spineguard. Royalties: VEPTR 2 device; Board of Directors: Children’s Spine Foundation Heflin: Consultant: Globus, Medtronic Morgan: Nothing to disclose

Background There are no established CPT codes to guide billing and reimbursement for growth-friendly spine procedures Billing and reimbursement is highly variable Most surgeons use unlisted procedure codes There is no consensus on how to bill for in-office lengthening of MCGR’s

Purpose Compare reimbursement for outpatient MCGR lengthening procedures to operative lengthening of growing rods or rib-based constructs

Methods Study period: 12/2014-06/2016 52 Rib-based constructs (RBC’s)with operative lengthening procedures 22 patients with in-office lengthening of magnetically controlled growing rods (MCGR’s) All procedures billed as unlisted (99) procedure codes Reimbursement compared to a level 5 office visit (99215)

Results: MCGR (Office) RBC (Operative) Level 5 Office visit Average billed charges $2151 $6885 $322 Average reimbursement Commercial $977 $4188 $252 Government $648 $2590 $124

Discussion Outpatient MCGR lengthening billed as a procedure code is reimbursed at a discounted rate ranging from 30-45% of billed charges Operative RBC lengthening procedures are reimbursed at a discounted rate of 42-69% Level 5 visits: Discounted 39-75%

Conclusion When billed as an outpatient procedure, reimbursement for lengthening of MCGR’s is significantly higher than a level 5 clinic visit With the lack of clearly defined codes for growth friendly surgical procedures, the correct way to charge for lengthening remains unclear

Limitations Single practice site, Surgeon experience Regional variation in billing and reimbursement practices nationally in the US

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