5.           Proposed new MBS schedule of items for spinal surgery

5.1        Current MBS items for spinal surgery

5.1.1        Issues

Data investigation of the current items for spinal surgery revealed the practice of surgeons claiming multiple spinal surgery items per episode of care, and there are variations in how combinations of items are claimed amongst providers. Section 5.1.2 provides further detail.

For the purposes of this report an episode of care includes services provided to a single patient on the same day, by the same provider. The issues of multiple item claiming and variation together suggest patients undergoing spinal surgery might receive different levels of Medicare benefits depending on the billing practice of their surgeon.

The Working Group identified many issues with the current schedule of spinal surgery items, including that:

 The current schedule of items is antiquated and does not reflect current spinal surgery practice.

 The current schedule mostly divides items by technique, anatomical site and pathology, leading to considerable variation in item utilisation.

 Current item descriptors are poorly written and can be ambiguous.

 Some current items represent inappropriate relative value.

 There is a lack of fit-for-purpose item numbers for procedures.

It is hypothesized that these issues have led to an inadequate system where the practice of claiming multiple items, as well as item claiming variation amongst providers, can prevail.

 

5.1.2        MBS data

Figure 1, Figure 2, Figure3 and Table C provide analysis of data for the MBS items for spinal surgery (items 40300 to 40351; 47681 to 47717; and 48600 to 48694).

Figure 1 and Figure 2 show the total number of services and total benefits paid (i.e. total Medicare expenditure) for the 74 spinal surgery items considered by the Committee. In the 2015-16 financial year, the 74 spinal items accounted for 79,934 services at a cost of $39.986 million to the MBS. 

Figure 1: MBS Items for Spinal Surgery, Total number of services, by financial year (2006-07 to 2015-16).

MBS Items for Spinal Surgery, Total number of services, by financial year (2006-07 to 2015-16).

Source: Department of Human Services, published data, date of processing.

Figure 2: MBS Items for Spinal Surgery, Total benefits paid, by financial year (2006-07 to 2015-16).

MBS Items for Spinal Surgery, Total benefits paid, by financial year (2006-07 to 2015-16).

Source: Department of Human Services, published data, date of processing.

Figure 3 shows that for each financial year between 2009-10 and 2015-16, there were nearly three times as many services compared to episodes, where an episode is defined as spinal surgery services provided to the same patient, on the same day by the same provider. The ratio of services to episodes has increased from 2.64 in 2009-10 to 2.95 in 2015-16.

Figure 3: MBS Items for Spinal Surgery, Total number of services and Total number of episodes, by financial year (2009-10 to 2015-16).

MBS Items for Spinal Surgery, Total number of services and Total number of episodes, by financial year (2009-10 to 2015-16).

Source: Department of Health, unpublished data, based on date of service using data processed up to 30 September 2016

Table C lists the top 10 combinations of items for spinal surgery, as the most common groupings/ways the items are claimed together. The combinations are limited to spinal surgery items. Table C shows that the top 10 item combination strings accounted for 52.6% of episodes in 2015-16. Of note, however, is that there were 1,581 different item combination strings that accounted for the remaining 47.4% of episodes.

Table C: MBS Items for Spinal Surgery, Top 10 item combinations, 2015-16.

Item combination

Number of episodes

40306,40330

2,926

40301,40330

2,518

40303,40330

2,225

40301,40303,40330

1,922

40300,40301,40330

1,262

40301,40306,40330

1,172

40301,40330,48660,48684

717

40300,40330

565

40306,40330,48648,48684

396

40301,40330,48669,48684

333

Source: Department of Health, unpublished data, based on date of service using data processed up to 30 September 2016

5.2        Recommended new MBS schedule of items for spinal surgery

The Committee endorsed the Working Groups proposal to replace the existing 74 items for spinal surgery with a new schedule of 59 items. The Committee also endorsed new rules to underpin the new schedule of items, further discussed at Section 6.1.

Recommendation 1

The Committee recommends that the current 74 items for spinal surgery (listed in Appendix A) are replaced by a new schedule of 59 items for spinal surgery, as outlined on pages 16 to 24.

Section 5.1 outlines the issues with the current 74 items for spinal surgery, which are the basis of the recommendation to replace the 74 existing items available with a new system of item claiming for spinal surgeons.

Together with meeting the goals of the Taskforce, the recommended new schedule of 59 items for spinal surgery seeks to:

 Accurately describe current spinal surgery practice.

 Increase uniformity of item utilisation for single procedures (e.g. discectomy).

 Reduce the total number of items.

 Improve relative value.

Proposed Schedule of Items for Adult Spinal Surgery

 These item numbers are used for all adult spinal pathologies including degenerative disease, infection, deformity (scoliosis and kyphosis), trauma, inflammatory conditions, primary and secondary vertebral column neoplasia.

 Paediatric deformity surgery and spinal implants for pain relief are covered by the existing schedule.

Guidelines

 For decompression procedures only one item is selected (from Table 1).

 For posterolateral spinal fusion without instrumentation, if a decompression is combined with the fusion, two item numbers are selected (with one number each from Tables 1 and 3).

 For posterolateral spinal fusion with instrumentation, two item numbers are selected (with one number each from Tables 2 and 3). If decompression is also performed, three items are selected (from each of Tables 1,2 and 3).

 For instrumented spinal fusion with interbody and posterolateral bone graft (with or without cages) and decompression, four item numbers are selected (with one number each from Tables 1, 2, 3 and 4).

 Combined anterior and posterior surgeries completed under one anaesthetic are billed using Table 6.

 Operations at two separate anatomical locations of the spine completed under one anaesthetic are billed as one operation.

Rules (Discussed further at recommendation 2).

 One item can be selected from each table, except for special items in Table 8. If the item description is not completed in full, the item number should not be used. It is not appropriate to use an item which is a “best guess” or approximate to what was done.

 Item numbers from the Spinal Section of the MBS cannot be combined with item numbers from other sections of the MBS.

 If an item is selected from Table 6, items from Tables 2, 3 or 4 cannot be combined with it. Table 6 assumes that a front and back combined procedure includes anterior and posterior bone grafting and instrumentation.

Table 1 Spinal Decompression (cervical, thoracic and lumbar)

Includes discectomy, decompression of central spinal canal by laminectomy or partial corpectomy (vertebral spurs and osteophytes; less than 50% of the vertebral body), and decompression of the subfacetal recess, the exit foramen and far lateral (intertransverse) space. If more than 50% of a vertebral body is resected (piecemeal vertebrectomy) an item number from Table 5 can also be selected.

A motion segment includes all anatomical structures (including traversing and exiting nerve roots) between and including the pedicles of two adjacent vertebrae.

Table 1: Only one item number can be selected

Item

Item descriptor

101

Spinal decompression via partial or total laminectomy or partial vertebrectomy, 1 motion segment (Anaes.) (Assist.)

102

Spinal decompression via partial or total laminectomy or partial vertebrectomy, 2 motion segments (Anaes.) (Assist.)

103

Spinal decompression via partial or total laminectomy or partial vertebrectomy, 3 motion segments (Anaes.) (Assist.)

104

Spinal decompression via partial or total laminectomy or partial vertebrectomy, 4 motion segments (Anaes.) (Assist.)

105

Spinal decompression via partial or total laminectomy or partial vertebrectomy, more than 4 motion segments (Anaes.) (Assist.)


Table 2 Spinal instrumentation (cervical, thoracic and lumbar)

Includes anterior and/or posterior instrumentation.

A motion segment includes all anatomical structures between and including the pedicles of two adjacent vertebrae. For example, a L4/5 instrumented fusion represents a fusion of a single motion segment.

Table 2: Only one item number can be selected

Item

Item descriptor

200

Simple fixation of part of one vertebra (not motion segment) including pars interarticularis, spinous process or pedicle or simple interspinous wiring between two adjacent vertebral levels (Anaes.) (Assist.)

201

Fixation of motion segment with vertebral body screw, pedicle screw or hook instrumentation including sublaminar tapes or wires, 1 motion segment (Anaes.) (Assist.)

202

Fixation of motion segment with vertebral body screw, pedicle screw or hook instrumentation including sublaminar tapes or wires, 2 motion segments (Anaes.) (Assist.)

203

Fixation of motion segment with vertebral body screw, pedicle screw or hook instrumentation including sublaminar tapes or wires, 3 or 4 motion segments (Anaes.) (Assist.)

204

Fixation of motion segment with vertebral body screw, pedicle screw or hook instrumentation including sublaminar tapes or wires, 5 or 6 motion segments (Anaes.) (Assist.)

205

Fixation of motion segment with vertebral body screw, pedicle screw or hook instrumentation including sublaminar tapes or wires, 7 to 12 motion segments (Anaes.) (Assist.)

206

Fixation of motion segment with vertebral body screw, pedicle screw or hook instrumentation including sublaminar tapes or wires, more than 12 motion segments (Anaes.) (Assist.)

Table 3 Posterior and/or Posterolateral (intertransverse or facet joint) bone graft (cervical, thoracic and lumbar)

Includes local morcellized, artificial or harvested bone graft with or without BMP (bone morphogenic protein).

A motion segment includes all anatomical structures between and including the pedicles of two adjacent vertebrae.

Table 3: Only one item number can be selected

Item

Item descriptor

301

SPINE, bone graft to, 1 motion segment (Anaes.) (Assist.)

302

SPINE, bone graft to, 2 motion segments (Anaes.) (Assist.)

303

SPINE, bone graft to, 3 motion segments (Anaes.) (Assist.)

304

SPINE, bone graft to, 4 to 7 motion segments (Anaes.) (Assist.)

305

SPINE, bone graft to, 8 to 11 motion segments (Anaes.) (Assist.)

306

SPINE, bone graft to, 12 or more motion segments (Anaes.) (Assist.)

Table 4 Anterior column fusion, with or without implant, or limited vertebrectomy (less than 50%) and anterior fusion, (cervical, thoracic and lumbar), via any approach.

Includes placement of local morcellized, artificial, harvested bone graft, BMP (bone morphogenic protein) and prosthetic devices into the intervertebral space.

A motion segment includes all anatomical structures between and including the pedicles of two adjacent vertebrae.

Numbers from this table are selected irrespective of surgical approach (anterior, direct lateral or posterior via open or minimally invasive techniques).

Table 4: Only one item number can be selected

Item

Item descriptor

401

SPINAL FUSION (anterior, direct lateral or posterior interbody)

1 motion segment (Anaes.) (Assist.)

402

SPINAL FUSION (anterior, direct lateral or posterior interbody)

2 motion segments (Anaes.) (Assist.)

403

SPINAL FUSION (anterior, direct lateral or posterior interbody)

3 motion segments (Anaes.) (Assist.)

404

SPINAL FUSION (anterior, direct lateral or posterior interbody)

4 motion segments (Anaes.) (Assist.)

405

SPINAL FUSION (anterior, direct lateral or posterior interbody)

5 or more motion segments (Anaes.) (Assist.)

Table 5 Spinal Osteotomy (cervical, thoracic and lumbar)

Major resection of sacral and pelvic tumours (malignant and benign) is covered by the existing schedule under subheading ‘Orthopaedic Malignant Disease’ (item numbers 50221 and 50224) or by using item numbers from the above five tables. A surgeon must not combine items from this section of ‘Adult Spinal Surgery’ with items from ‘Orthopaedic Malignant Disease’.

Table 5: Only one item number can be selected

Item

Item descriptor

501

Pedicle Subtraction Osteotomy, 1 motion segment

(not to be used with item numbers from Table 4 at the same motion segment) (Anaes.) (Assist.)

502

Pedicle Subtraction Osteotomy, 2 motion segments

(not to be used with item numbers from Table 4 at the same motion segment) (Anaes.) (Assist.)

503

Vertebral Column Resection Osteotomy performed through single posterior approach, 1 motion segment

(not to be used with item numbers from Table 4 at the same motion segment) (Anaes.) (Assist.)

504

VERTEBRAL BODY, piece meal1 or subtotal excision of, 1 vertebra (not to be combined with item number from Table 1) (Anaes.) (Assist.)

505

VERTEBRAL BODY, piece meal1  or subtotal excision of, 2 vertebrae (not to be combined with item number from Table 1) (Anaes.) (Assist.)

506

VERTEBRAL BODY, piece meal1 or subtotal excision of, 3 or more vertebrae (not to be combined with item number from Table 1) (Anaes.) (Assist.)

507

VERTEBRAL BODY, en bloc excision of (complete spondylectomy), 1 vertebra (not to be combined with item number from Table 1) (Anaes.) (Assist.)

508

VERTEBRAL BODY, en bloc excision of (complete spondylectomy), 2 vertebrae (not to be combined with item number from Table 1) (Anaes.) (Assist.)

509

VERTEBRAL BODY, en bloc excision of (complete spondylectomy), 3 or more vertebrae (not to be combined with item number from Table 1) (Anaes.) (Assist.)

1 piecemeal vertebrectomy is defined as removal of more than 50% of the vertebral body. If less than 50% of the vertebral body is removed an appropriate number from Table 4 should be used.


Table 6 Anterior and Posterior (Combined) Spinal Fusion under One Anaesthetic via Separate Incisions

If Table 6 is used, items numbers from Table 2, 3 or 4 cannot be combined. Table 6 assumes that a front and back combined procedure includes anterior and posterior bone grafting and instrumentation.

The numbers in this table don’t assume a laminectomy or spinal osteotomy are necessarily performed.

From now, if canal decompression is performed (from either a front or back approach) a single number from Table 1 is added.

Similarly, if a spinal osteotomy is performed as part of the combined front and back procedure, a single number from Table 5 is added.

Table 6: Only one item number can be selected

Item

Item descriptor

601

SPINE FUSION, anterior and posterior, 1 motion segment (Anaes.) (Assist.)

602

SPINE FUSION, anterior and posterior, 2 motion segments (Anaes.) (Assist.)

603

SPINE FUSION, anterior and posterior, 3 motion segments (Anaes.) (Assist.)

604

SPINE FUSION, anterior and posterior, 4 to 7 motion segments (Anaes.) (Assist.)

605

SPINE FUSION, anterior and posterior, 8 to 11 motion segments (Anaes.) (Assist.)

606

SPINE FUSION, anterior and posterior, 12 or more motion segments (Anaes.) (Assist.)

Note: The number of levels chosen is based on the extent of posterior bone grafting and fusion. For example, a 4 level anterior release and bone graft with T3-12 posterior instrumentation and posterolateral bone graft is billed as an 8 level procedure, namely Item 605.

If a laminectomy is included in the procedure, an Item from Table 1 is added depending on the number of levels that were decompressed.

Similarly, if a spinal osteotomy is undertaken as part of the front and back combined procedure then a number from Table 5 is added.


Table 7 Intradural Procedures

Table 7: Only one item number can be selected

Item

Item descriptor

701

Removal of INTRADURAL LESION (Anaes.) (Assist.)

702

CRANIOCERVICAL JUNCTION LESION, transoral approach for (Anaes.) (Assist.)

703

Removal of INTRAMEDULLARY TUMOUR OR ARTERIOVENOUS MALFORMATION (Anaes.) (Assist.)

 

Table 8 Miscellaneous Spinal Procedures (cervical, thoracic and lumbar)

Table 8: One or more item number(s) can be selected

Item

Item descriptor

802

THORACOPLASTY in combination with thoracic scoliosis correction - 3 or more ribs (Anaes.) (Assist.)

803

ODONTOID screw fixation (Anaes.) (Assist.)

(Not to be used with other item numbers)

810

SPINE, treatment of fracture, dislocation or fracture-dislocation, with immobilisation by calipers or halo (Anaes.)

811

SKULL CALIPERS or HALO, insertion of, as an independent procedure (Anaes.)

812

PLASTER JACKET, application of, as an independent procedure (Anaes.)

813

HALO, application of, in addition to spinal fusion for scoliosis, or other conditions (Anaes.)

814

HALO-THORACIC Orthosis - application of both halo and thoracic jacket (Anaes.)

815

HALO-FEMORAL TRACTION, as an independent procedure (Anaes.)

820

BONE GRAFT, harvesting of autogenous graft, via separate incision or via subcutaneous approach, in conjunction with spinal fusion (Anaes.)

830

Lumbar artificial intervertebral total disc replacement, at 1 motion segment only, including removal of disc and marginal osteophytes, for a patient who:

(a) has not had prior spinal fusion surgery at the same lumbar level; and

(b) does not have vertebral osteoporosis; and

(c) has failed conservative therapy (Anaes.) (Assist.)

831

Cervical artificial intervertebral total disc replacement, at 1 motion segment only, including removal of disc and marginal osteophytes, for a patient who:

(a) has not had prior spinal surgery at the same cervical level; and

(b) is skeletally mature; and

(c) has symptomatic degenerative disc disease with radiculopathy; and

(d) does not have vertebral osteoporosis; and

(e) has failed conservative therapy  (Anaes.) (Assist.)

840

Previous Spinal Fusion, re-exploration for, involving adjustment or removal of instrumentation up to 4 vertebral levels

841

Previous Spinal Fusion, re-exploration for, involving adjustment or removal of instrumentation more than 4 vertebral levels

845

Wound debridement or excision for post-operative infection or haematoma following spinal surgery

850

Coccyx, excision of

860

Anterior exposure of thoracic or lumbar spine2

870

Syringomyelia or Hydromyelia, craniotomy for, with or without duraplasty, intradural dissection, plugging of obex or local Cerebrospinal Fluid Shunt

871

Syringomyelia or Hydromyelia, treatment by direct Cerebrospinal Fluid Shunt e.g. Syringosubarachnoid shunt, Syringopleural shunt, Syringoperitoneal shunt

2 If the spine surgeon performs his or her own exposure to the thoracic or lumbar spine then this item number is added to the item numbers used for the overall surgery. If an exposure surgeon is used at any time during the procedure, then this number is used in isolation by the exposure surgeon. If the exposure surgeon needs to perform complex non spinal surgery, they may use a more appropriate number but not in combination with 860. If an exposure surgeon claims a number from any section of the MBS Schedule, the spinal surgeon cannot claim number 860.