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Level of Care for Musculoskeletal Surgery 2024-01-01

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Status: Reaffirmed Effective Date: 01/01/2024

Doc ID: MSK04-0124.1-R0424 Last Review Date: 04/15/2024

Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details.

Clinical Appropriateness Guidelines

Musculoskeletal

Appropriate Use Criteria: Level of Care for Musculoskeletal Surgery

“Site of Care,” “Site of Service” or another term such as “Setting” or “Place of Service” may be terms used in benefit plans, provider contracts, or other materials instead of or in addition to “Level of Care” and, in some plans, these terms may be used interchangeably.

Proprietary

© 2024 Carelon Medical Benefits Management, Inc. All rights reserved.

Table of Contents

Description and Application of the Guidelines

General Clinical Guideline

Level of Care Guidelines for Musculoskeletal Surgery

Scope

Definitions

Guidelines

References

Codes

Appendix

History

Description and Application of the Guidelines

The Carelon Clinical Appropriateness Guidelines (hereinafter “the Carelon Clinical Appropriateness Guidelines” or the “Guidelines”) are designed to assist providers in making the most appropriate treatment decision for a specific clinical condition for an individual. The Guidelines establish objective and evidence-based criteria for medical necessity determinations, where possible, that can be used in support of the following:

  • To establish criteria for when services are medically necessary
  • To assist the practitioner as an educational tool
  • To encourage standardization of medical practice patterns
  • To curtail the performance of inappropriate and/or duplicate services
  • To address patient safety concerns
  • To enhance the quality of health care
  • To promote the most efficient and cost-effective use of services

The Carelon guideline development process complies with applicable accreditation and legal standards, including the requirement that the Guidelines be developed with involvement from appropriate providers with current clinical expertise relevant to the Guidelines under review and be based on the most up-to-date clinical principles and best practices. Resources reviewed include widely used treatment guidelines, randomized controlled trials or prospective cohort studies, and large systematic reviews or meta-analyses. Carelon reviews all of its Guidelines at least annually.

Carelon makes its Guidelines publicly available on its website. Copies of the Guidelines are also available upon oral or written request. Additional details, such as summaries of evidence, a list of the sources of evidence, and an explanation of the rationale that supports the adoption of the Guidelines, are included in each guideline document.

Although the Guidelines are publicly available, Carelon considers the Guidelines to be important, proprietary information of Carelon, which cannot be sold, assigned, leased, licensed, reproduced or distributed without the written consent of Carelon.

Carelon applies objective and evidence-based criteria, and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. The Carelon Guidelines are just guidelines for the provision of specialty health services. These criteria are designed to guide both providers and reviewers to the most appropriate services based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice should be used when applying the Guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity for the requested service. The Guidelines are not a substitute for the experience and judgment of a physician or other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment.

The Guidelines do not address coverage, benefit or other plan specific issues. Applicable federal and state coverage mandates take precedence over these clinical guidelines, and in the case of reviews for Medicare Advantage Plans, the Guidelines are only applied where there are not fully established CMS criteria. If requested by a health plan, Carelon will review requests based on health plan medical policy/guidelines in lieu of the Carelon Guidelines. Pharmaceuticals, radiotracers, or medical devices used in any of the diagnostic or therapeutic interventions listed in the Guidelines must be FDA approved or conditionally approved for the intended use. However, use of an FDA approved or conditionally approved product does not constitute medical necessity or guarantee reimbursement by the respective health plan.

The Guidelines may also be used by the health plan or by Carelon for purposes of provider education, or to review the medical necessity of services by any provider who has been notified of the need for medical necessity review, due to billing practices or claims that are not consistent with other providers in terms of frequency or some other manner.

General Clinical Guideline

Clinical Appropriateness Framework

Critical to any finding of clinical appropriateness under the guidelines for a specific diagnostic or therapeutic intervention are the following elements:

  • Prior to any intervention, it is essential that the clinician confirm the diagnosis or establish its pretest likelihood based on a complete evaluation of the patient. This includes a history and physical examination and, where applicable, a review of relevant laboratory studies, diagnostic testing, and response to prior therapeutic intervention.
  • The anticipated benefit of the recommended intervention is likely to outweigh any potential harms, including from delay or decreased access to services that may result (net benefit).
  • Widely used treatment guidelines and/or current clinical literature and/or standards of medical practice should support that the recommended intervention offers the greatest net benefit among competing alternatives.
  • There exists a reasonable likelihood that the intervention will change management and/or lead to an improved outcome for the patient.

Providers may be required to submit clinical documentation in support of a request for services. Such documentation must a) accurately reflect the clinical situation at the time of the requested service, and b) sufficiently document the ordering provider’s clinical intent.

If these elements are not established with respect to a given request, the determination of appropriateness will most likely require a peer-to-peer conversation to understand the individual and unique facts that would justify a finding of clinical appropriateness. During the peer-to-peer conversation, factors such as patient acuity and setting of service may also be taken into account to the extent permitted by law.

Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions

Requests for multiple diagnostic or therapeutic interventions at the same time will often require a peer-to-peer conversation to understand the individual circumstances that support the medical necessity of performing all interventions simultaneously. This is based on the fact that appropriateness of additional intervention is often dependent on the outcome of the initial intervention.

Additionally, either of the following may apply:

  • Current literature and/or standards of medical practice support that one of the requested diagnostic or therapeutic interventions is more appropriate in the clinical situation presented; or
  • One of the diagnostic or therapeutic interventions requested is more likely to improve patient outcomes based on current literature and/or standards of medical practice.

Repeat Diagnostic Intervention

In general, repeated testing of the same anatomic location for the same indication should be limited to evaluation following an intervention, or when there is a change in clinical status such that additional testing is required to determine next steps in management. At times, it may be necessary to repeat a test using different techniques or protocols to clarify a finding or result of the original study.

Repeated testing for the same indication using the same or similar technology may be subject to additional review or require peer-to-peer conversation in the following scenarios:

  • Repeated diagnostic testing at the same facility due to technical issues
  • Repeated diagnostic testing requested at a different facility due to provider preference or quality concerns
  • Repeated diagnostic testing of the same anatomic area based on persistent symptoms with no clinical change, treatment, or intervention since the previous study
  • Repeated diagnostic testing of the same anatomic area by different providers for the same member over a short period of time

Repeat Therapeutic Intervention

In general, repeated therapeutic intervention in the same anatomic area is considered appropriate when the prior intervention proved effective or beneficial and the expected duration of relief has lapsed. A repeat intervention requested prior to the expected duration of relief is not appropriate unless it can be confirmed that the prior intervention was never administered. Requests for ongoing services may depend on completion of previously authorized services in situations where a patient’s response to authorized services is relevant to a determination of clinical appropriateness.

Level of Care Guidelines for Musculoskeletal Surgery

“Site of Care,” “Site of Service” or another term such as “Setting” or “Place of Service” may be terms used in benefit plans, provider contracts, or other materials instead of or in addition to “Level of Care” and, in some plans, these terms may be used interchangeably.

Scope

Evidence is growing that supports the safety and effectiveness of the outpatient surgery setting for many orthopedic and spine surgical procedures. Procedures that have historically been performed in the inpatient setting are now being successfully performed in the outpatient surgery setting. Factors that have contributed to this movement include:

  • Equal or better outcomes compared to inpatient setting
  • Minimal invasive techniques and improved surgical technologies
  • Improved anesthesia techniques and more effective postoperative pain management
  • Lower costs and operational efficiency

Appropriate patient selection for the outpatient setting is paramount. It may be medically necessary for patients with certain risk factors and undergoing certain procedures to have their procedures performed in the inpatient setting.

The intent of this guideline is to assist in determining the appropriate level of care necessary to perform the intended surgical procedure safely and effectively. Provider should submit the required supporting medical documentation to include but not limited to the following:

  • Provider office notes detailing preoperative medical optimization
  • List of managed or unmanaged comorbidities and/or other surgical risk factors
  • If requested, the specific reason for an inpatient preoperative day
  • Copies of medical consultations or clearances
  • American Society of Anesthesiologists (ASA) physical status (see Appendix), Charlson Comorbidity Index score, or other validated surgical risk score, if necessary, to support the requested level of care

This guideline does not address the medical necessity of the procedure itself. The prior authorization process for medical necessity of the surgical procedure is completed separately and precedes the level of care determination. The procedure must meet the respective Carelon musculoskeletal surgery guideline for clinical appropriateness prior to level of care determination.

Definitions

Outpatient Surgical Setting

An outpatient surgical procedure is defined as one where a patient arrives and is registered at a setting other than the acute inpatient hospital setting, undergoes the procedure, and is discharged the same day or within the timeframe for observation defined by patient’s health plan contract and/or local government regulatory agency. Such settings may include Observation Care, Hospital Outpatient Department (on or off campus), Ambulatory Surgical Center, or Physician Office. For the purposes of this guideline, procedures performed in a Physician Office are out of scope.

Observation Surgical Setting

Observation is a special form of hospital outpatient care that provides interim services in place of an inpatient admission to allow for a reasonable period of time to evaluate and determine the need for further treatment or for inpatient admission. There is evidence that the characteristics of observation care in clinical practice differ from the Centers for Medicare & Medicaid Services definition and that use of observation care is growing with short inpatient stays being the third most common reason to admit for observation. Individual cases admitted to Observation Care may undergo concurrent clinical review to assess the need for transfer to acute inpatient setting. Maximum length of stay in Observation Care is governed by the patient’s health plan contract and/or local government regulatory agency.

Surgeons who request inpatient admission for an outpatient musculoskeletal procedure and who decline Observation Care will need to provide clinical documentation to support the need for direct admission to an acute inpatient setting.

Inpatient Surgical Setting

The inpatient surgical setting, rather than the outpatient setting, is required only if the patient’s safety or health would be significantly and directly threatened if care were provided in a less intensive setting. The selection of surgical setting is not justified when it is solely for the convenience of the patient, the patient’s family, or the provider.

Guidelines

Acute Inpatient Surgical Setting

The acute inpatient surgical setting may be considered medically necessary when at least ONE of the following requirements are met:

  • Current postoperative care requirements are of such intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
  • Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.

Observation Outpatient Surgical Setting

The observation surgical setting may be considered medically necessary in patients with ONE or more preprocedural clinical risk factors that increase the likelihood of inpatient admission.

Note: The presence of medical and/or psychiatric comorbidities alone may not always justify an observation surgical setting, but consideration should be given if poorly controlled, unstable, untreated, or anticipated to require treatment postoperatively.

Demographic/constitutional

  • Age 65 years or older
  • BMI greater than 40 kg/m2
  • Pregnancy

Medical risk factors

  • Charlson Comorbidity Index score greater than 2, ASA class greater than 2, or other attestation of comorbid status
  • Recent venous thromboembolic event
  • Severe or uncontrolled diabetes
  • Severe anemia (e.g., hemoglobin ≤ 10)
  • Coagulopathy
  • Recent unexplained weight loss
  • Malnutrition
  • Chronic pulmonary disease
    • COPD, severe and/or oxygen dependent
    • Respiratory distress
  • Obstructive sleep apnea
  • Liver disease including but not limited to cirrhosis
  • Vascular
    • Cardiovascular disease
      • Myocardial infarction within 6 months of intended surgery
      • Angina pectoris with severe functional limitation
      • Cardiac arrhythmia
      • Implantable cardiac device (defibrillator, pacemaker)
      • Congestive heart failure
    • Cerebrovascular disease
      • Recent stroke or transient ischemic attack
    • Uncontrolled preoperative pain
    • Prior complication of anesthesia
    • Prior postoperative complication
      • Ileus
      • Urinary retention

Psychiatric/cognitive

  • Ongoing substance abuse
  • Cognitive impairment

Functional status

  • Patient unable to care for individual needs
  • Functional impairment likely to necessitate inpatient rehabilitation after surgery (example: moderate to severe myelopathy)
  • Patient is at high risk for falls

Outpatient Surgical Setting (excluding Observation)

The non-observation surgical setting includes Ambulatory Surgery Center or Hospital-based Outpatient Department and may be considered medically necessary for elective spine and joint surgery in low-risk patients and procedures as follows:

Note: These requirements do not prohibit providers from performing these procedures in Ambulatory Surgery Center for carefully selected higher risk patients (e.g., physiologic age < biological age, medically optimized, uneventful prior procedure) according to their professional medical judgement.

Hospital-based outpatient department

Patient meets ALL of the following:

  • Age 64 years or younger
  • BMI less than or equal to 40 kg/m2
  • Low medical comorbidity risk
  • Safe post-surgical disposition

All necessary staff, equipment, and resources are available to perform the requested procedure safely and effectively in an ambulatory surgical center.

  • Cervical
    • One- or two-level anterior cervical discectomy and fusion (ACDF) between C3 and C7
    • One- or two-level cervical disc arthroplasty between C3 and C7
    • One- or two-level foraminotomy
    • Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural
  • Thoracic
    • Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural
  • Lumbar
    • One- or two-level discectomy and/or decompression (laminectomy, laminotomy, or foraminotomy)
    • One- or two-level posterior or posterolateral with posterior interbody fusion
    • Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural
  • Sacral
    • Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural
  • Vertebroplasty
  • Kyphoplasty
  • Joint
    • Total or partial primary hip arthroplasty for unilateral osteoarthritis
    • Total or partial primary knee arthroplasty for unilateral osteoarthritis
Ambulatory surgery center with 23-hour observation

Patient meets ALL of the following:

  • Age 64 years or younger
  • BMI less than or equal to 40 kg/m2
  • Low medical comorbidity risk
  • Safe post-surgical disposition

All necessary staff, equipment, and resources are available to perform the requested procedure safely and effectively in the ambulatory surgical center.

  • Cervical
    • One- or two-level anterior cervical discectomy and fusion (ACDF) between C3 and C7
    • One- or two-level cervical disc arthroplasty between C3 and C7
    • One- or two-level foraminotomy
    • Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural
  • Thoracic
    • Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural
  • Lumbar
    • One- or two-level discectomy and/or decompression (laminectomy, laminotomy, or foraminotomy)
    • One- or two-level posterior or posterolateral with posterior interbody fusion
    • Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural
  • Sacral
    • Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural
  • Vertebroplasty
  • Kyphoplasty
  • Joint
    • Total or partial primary shoulder arthroplasty
    • Total or partial primary hip arthroplasty for unilateral osteoarthritis
    • Total or partial primary knee arthroplasty for unilateral osteoarthritis

Facility has the capability for minimum of 23-hour observation.

Ambulatory surgery center with or without 23-hour observation

The following procedure can be safely performed in the Ambulatory Surgical Center with or without 23 hours of observation.

  • Arthroscopy

References

Joint Surgery

  1. Observation or inpatient? get it right up front. Hosp Case Manag. 2012;20(1):1-3.
  2. Ahmed AF, Hantouly A, Toubasi A, et al. The safety of outpatient total shoulder arthroplasty: a systematic review and meta-analysis. Int Orthop. 2021;45(3):697-710.
  3. Allahabadi S, Cheung EC, Hodax JD, et al. Outpatient Shoulder Arthroplasty-A Systematic Review. J Shoulder Elb Arthroplast. 2021;5:24715492211028025.
  4. Basques BA, Erickson BJ, Leroux T, et al. Comparative outcomes of outpatient and inpatient total shoulder arthroplasty: an analysis of the Medicare dataset. Bone Joint J. 2017;99-B(7):934-8.
  5. Berstock JR, Beswick AD, Lenguerrand E, et al. Mortality after total hip replacement surgery: A systematic review. Bone Joint Res. 2014;3(6):175-82.
  6. Bovonratwet P, Webb ML, Ondeck NT, et al. Definitional Differences of ‘Outpatient’ Versus ‘Inpatient’ THA and TKA Can Affect Study Outcomes. Clin Orthop Relat Res. 2017;475(12):2917-25.
  7. Bradley B, Middleton S, Davis N, et al. Discharge on the day of surgery following unicompartmental knee arthroplasty within the United Kingdom NHS. Bone Joint J. 2017;99-B(6):788-92.
  8. Brolin TJ, Mulligan RP, Azar FM, et al. Neer Award 2016: Outpatient total shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total shoulder arthroplasty in a hospital: a matched cohort study. J Shoulder Elbow Surg. 2017;26(2):204-8.
  9. Cancienne JM, Brockmeier SF, Gulotta LV, et al. Ambulatory Total Shoulder Arthroplasty: A Comprehensive Analysis of Current Trends, Complications, Readmissions, and Costs. J Bone Joint Surg Am. 2017;99(8):629-37.
  10. Carbone A, Vervaecke AJ, Ye IB, et al. Outpatient versus inpatient total shoulder arthroplasty: A cost and outcome comparison in a comorbidity matched analysis. J Orthop. 2021;28:126-33.
  11. Cimino AM, Hawkins JK, McGwin G, et al. Is outpatient shoulder arthroplasty safe? A systematic review and meta-analysis. J Shoulder Elbow Surg. 2021;30(8):1968-76.
  12. Colvin AC, Egorova N, Harrison AK, et al. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94(3):227-33.
  13. Courtney PM, Boniello AJ, Berger RA. Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database. J Arthroplasty. 2017;32(5):1426-30.
  14. De Beule J, Vandenneucker H, Claes S, et al. Can anterior cruciate ligament reconstruction be performed routinely in day clinic? Acta Orthop Belg. 2014;80(3):391-6.
  15. Erickson BJ, Shishani Y, Jones S, et al. Outpatient vs. inpatient reverse total shoulder arthroplasty: outcomes and complications. J Shoulder Elbow Surg. 2020;29(6):1115-20.
  16. Gauthier-Kwan OY, Dobransky JS, Dervin GF. Quality of Recovery, Postdischarge Hospital Utilization, and 2-Year Functional Outcomes After an Outpatient Total Knee Arthroplasty Program. J Arthroplasty. 2018;33(7):2159-64.e1.
  17. Goyal N, Chen AF, Padgett SE, et al. Otto Aufranc Award: A Multicenter, Randomized Study of Outpatient versus Inpatient Total Hip Arthroplasty. Clin Orthop Relat Res. 2017;475(2):364-72.
  18. Gromov K, Jorgensen CC, Petersen PB, et al. Complications and readmissions following outpatient total hip and knee arthroplasty: a prospective 2-center study with matched controls. Acta Orthop. 2019;90(3):281-5.
  19. Guareschi AS, Eichinger JK, Friedman RJ. Patient outcomes after revision total shoulder arthroplasty in an inpatient vs. outpatient setting. J Shoulder Elbow Surg. 2022;09:09.
  20. Hoffmann JD, Kusnezov NA, Dunn JC, et al. The Shift to Same-Day Outpatient Joint Arthroplasty: A Systematic Review. J Arthroplasty. 2018;33(4):1265-74.
  21. Hofstede SN, Gademan MG, Vliet Vlieland TP, et al. Preoperative predictors for outcomes after total hip replacement in patients with osteoarthritis: a systematic review. BMC Musculoskelet Disord. 2016;17:212.
  22. Huang A, Ryu JJ, Dervin G. Cost savings of outpatient versus standard inpatient total knee arthroplasty. Can J Surg. 2017;60(1):57-62.
  23. Huddleston HP, Mehta N, Polce EM, et al. Complication rates and outcomes after outpatient shoulder arthroplasty: a systematic review. JSES Int. 2021;5(3):413-23.
  24. Iyengar JJ, Samagh SP, Schairer W, et al. Current trends in rotator cuff repair: surgical technique, setting, and cost. Arthroscopy. 2014;30(3):284-8.
  25. Kadhim M, Gans I, Baldwin K, et al. Do Surgical Times and Efficiency Differ Between Inpatient and Ambulatory Surgery Centers That are Both Hospital Owned? J Pediatr Orthop. 2016;36(4):423-8.
  26. Klapwijk LC, Mathijssen NM, Van Egmond JC, et al. The first 6 weeks of recovery after primary total hip arthroplasty with fast track. Acta Orthop. 2017;88(2):140-4.
  27. Kolisek FR, McGrath MS, Jessup NM, et al. Comparison of outpatient versus inpatient total knee arthroplasty. Clin Orthop Relat Res. 2009;467(6):1438-42.
  28. Kucharik MP, Varady NH, Best MJ, et al. Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score-matched analysis of 20,035 procedures. JSES Int. 2022;6(1):15-20.
  29. Kunutsor SK, Whitehouse MR, Blom AW, et al. Patient-Related Risk Factors for Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PloS one. 2016;11(3):e0150866.
  30. Lang SS, Chen HI, Koch MJ, et al. Development of an outpatient protocol for lumbar discectomy: our institutional experience. World Neurosurg. 2014;82(5):897-901.
  31. Lee DK, Kim HJ, Lee DH. Incidence of Deep Vein Thrombosis and Venous Thromboembolism following TKA in Rheumatoid Arthritis versus Osteoarthritis: A Meta-Analysis. PloS one. 2016;11(12):e0166844.
  32. Lefevre N, Klouche S, de Pamphilis O, et al. Postoperative discomfort after outpatient anterior cruciate ligament reconstruction: a prospective comparative study. Orthop Traumatol Surg Res. 2015;101(2):163-6.
  33. Leroux TS, Basques BA, Frank RM, et al. Outpatient total shoulder arthroplasty: a population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25(11):1780-6.
  34. Lovald ST, Ong KL, Malkani AL, et al. Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients. J Arthroplasty. 2014;29(3):510-5.
  35. Lovecchio F, Alvi H, Sahota S, et al. Is Outpatient Arthroplasty as Safe as Fast-Track Inpatient Arthroplasty? A Propensity Score Matched Analysis. J Arthroplasty. 2016;31(9 Suppl):197-201.
  36. Lyman S, Koulouvaris P, Sherman S, et al. Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am. 2009;91(10):2321-8.
  37. Malahias MA, Kokkineli S, Gu A, et al. Day case versus inpatient total shoulder arthroplasty: A systematic review and meta-analysis. Shoulder Elbow. 2021;13(5):471-81.
  38. Maletis GB, Inacio MC, Reynolds S, et al. Incidence of symptomatic venous thromboembolism after elective knee arthroscopy. J Bone Joint Surg Am. 2012;94(8):714-20.
  39. Mall NA, Chalmers PN, Moric M, et al. Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med. 2014;42(10):2363-70.
  40. McGirt MJ, Godil SS, Asher AL, et al. Quality analysis of anterior cervical discectomy and fusion in the outpatient versus inpatient setting: analysis of 7288 patients from the NSQIP database. Neurosurg Focus. 2015;39(6):E9.
  41. Mulligan RP, Parekh SG. Safety of Outpatient Total Ankle Arthroplasty vs Traditional Inpatient Admission or Overnight Observation. Foot Ankle Int. 2017;38(8):825-31.
  42. Nelson SJ, Webb ML, Lukasiewicz AM, et al. Is Outpatient Total Hip Arthroplasty Safe? J Arthroplasty. 2017;32(5):1439-42.
  43. Ode GE, Odum S, Connor PM, et al. Ambulatory versus inpatient shoulder arthroplasty: a population-based analysis of trends, outcomes, and charges. JSES Int. 2020;4(1):127-32.
  44. Overman RA, Freburger JK, Assimon MM, et al. Observation stays in administrative claims databases: underestimation of hospitalized cases. Pharmacoepidemiol Drug Saf. 2014;23(9):902-10.
  45. Parcells BW, Giacobbe D, Macknet D, et al. Total Joint Arthroplasty in a Stand-alone Ambulatory Surgical Center: Short-term Outcomes. Orthopedics. 2016;39(4):223-8.
  46. Perera E, Flood B, Madden K, et al. A systematic review of clinical outcomes for outpatient vs. inpatient shoulder arthroplasty. Shoulder Elbow. 2022;14(5):523-33.
  47. Puzzitiello RN, Moverman MA, Pagani NR, et al. Current Status Regarding the Safety of Inpatient Versus Outpatient Total Shoulder Arthroplasty: A Systematic Review. Hss J. 2022;18(3):428-38.
  48. Sandler AB, Scanaliato JP, Narimissaei D, et al. The transition to outpatient shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2022;31(7):e315-e31.
  49. Schuttler S, Andjelkov N. Articular cartilage surgery in outpatients: a pilot study. J Knee Surg. 2011;24(2):125-7.
  50. Schwappach DL, Strasmann TJ. Does location matter? A study of the public’s preferences for surgical care provision. J Eval Clin Pract. 2007;13(2):259-64.
  51. Sheehy AM, Graf B, Gangireddy S, et al. Hospitalized but not admitted: characteristics of patients with “observation status” at an academic medical center. JAMA Intern Med. 2013;173(21):1991-8.
  52. Si HB, Zeng Y, Shen B, et al. The influence of body mass index on the outcomes of primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2015;23(6):1824-32.
  53. Simon CB, Coronado RA, Greenfield WH, 3rd, et al. Predicting Pain and Disability After Shoulder Arthroscopy: Rotator Cuff Tear Severity and Concomitant Arthroscopic Procedures. Clin J Pain. 2016;32(5):404-10.
  54. Springer BD, Odum SM, Vegari DN, et al. Impact of Inpatient Versus Outpatient Total Joint Arthroplasty on 30-Day Hospital Readmission Rates and Unplanned Episodes of Care. Orthop Clin North Am. 2017;48(1):15-23.
  55. Trudeau MT, Peters JJ, LeVasseur MR, et al. Inpatient versus outpatient shoulder arthroplasty outcomes: A propensity score matched risk-adjusted analysis demonstrates the safety of outpatient shoulder arthroplasty. J Isakos. 2022;7(2):51-5.
  56. Valkering KP, van Bergen CJ, Buijze GA, et al. Pain experience and functional outcome of inpatient versus outpatient anterior cruciate ligament reconstruction, an equivalence randomized controlled trial with 12 months follow-up. Knee. 2015;22(2):111-6.
  57. Willenbring TJ, DeVos MJ, Kozemchak AM, et al. Is outpatient shoulder arthroplasty safe in patients aged >=65 years? A comparison of readmissions and complications in inpatient and outpatient settings. J Shoulder Elbow Surg. 2021;30(10):2306-11.

Spine Surgery

  1. Observation or inpatient? get it right up front. Hosp Case Manag. 2012;20(1):1-3.
  2. Abdallah DY, Jadaan MM, McCabe JP. Body mass index and risk of surgical site infection following spine surgery: a meta-analysis. Eur Spine J. 2013;22(12):2800-9.
  3. Adamson T, Godil SS, Mehrlich M, et al. Anterior cervical discectomy and fusion in the outpatient ambulatory surgery setting compared with the inpatient hospital setting: analysis of 1000 consecutive cases. J Neurosurg Spine. 2016;24(6):878-84.
  4. Arshi A, Park HY, Blumstein GW, et al. Outpatient Posterior Lumbar Fusion: A Population-Based Analysis of Trends and Complication Rates. Spine (Phila Pa 1976). 2018;43(22):1559-65.
  5. Ban D, Liu Y, Cao T, et al. Safety of outpatient anterior cervical discectomy and fusion: a systematic review and meta-analysis. Eur J Med Res. 2016;21(1):34.
  6. Bernatz JT, Anderson PA. Thirty-day readmission rates in spine surgery: systematic review and meta-analysis. Neurosurg Focus. 2015;39(4):E7.
  7. Best NM, Sasso RC. Outpatient lumbar spine decompression in 233 patients 65 years of age or older. Spine (Phila Pa 1976). 2007;32(10):1135-9; discussion 40.
  8. Bovonratwet P, Ottesen TD, Gala RJ, et al. Outpatient elective posterior lumbar fusions appear to be safely considered for appropriately selected patients. Spine J. 2018;18(7):1188-96.
  9. Chin KR, Pencle FJ, Coombs AV, et al. Lateral Lumbar Interbody Fusion in Ambulatory Surgery Centers: Patient Selection and Outcome Measures Compared With an Inhospital Cohort. Spine (Phila Pa 1976). 2016;41(8):686-92.
  10. Debono B, Sabatier P, Garnault V, et al. Outpatient Lumbar Microdiscectomy in France: From an Economic Imperative to a Clinical Standard-An Observational Study of 201 Cases. World Neurosurg. 2017;106:891-7.
  11. Di Capua J, Somani S, Kim JS, et al. Analysis of Risk Factors for Major Complications Following Elective Posterior Lumbar Fusion. Spine (Phila Pa 1976). 2017;42(17):1347-54.
  12. Emami A, Faloon M, Issa K, et al. Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Outpatient Setting. Orthopedics. 2016;39(6):e1218-e22.
  13. Ernst AA, Jones J, Weiss SJ, et al. Emergency department orthopedics observation unit as an alternative to admission. South Med J. 2014;107(10):648-53.
  14. Fallah A, Massicotte EM, Fehlings MG, et al. Admission and acute complication rate for outpatient lumbar microdiscectomy. Can J Neurol Sci. 2010;37(1):49-53.
  15.  Fei Q, Li J, Lin J, et al. Risk Factors for Surgical Site Infection After Spinal Surgery: A Meta-Analysis. World Neurosurg. 2016;95:507-15.
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  18. Kurtz SM, Lau E, Ong KL, et al. Infection risk for primary and revision instrumented lumbar spine fusion in the Medicare population. J Neurosurg Spine. 2012;17(4):342-7.
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  26. McGirt MJ, Godil SS, Asher AL, et al. Quality analysis of anterior cervical discectomy and fusion in the outpatient versus inpatient setting: analysis of 7288 patients from the NSQIP database. Neurosurg Focus. 2015;39(6):E9.
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Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Medical necessity reviews are initiated by submitting the correct AMA CPT codes. Specific CPT codes for services should be used when available. The submitted codes must accurately identify the service or procedure to be performed. If no such code exists, contact the health plan directly and report the service or procedure using the appropriate unlisted procedure or Not Otherwise Classified (NOC) code (which often ends in 99). Do not submit a code that is “close to” the procedure performed in lieu of an unlisted code. Correct coding demands that the code reported is appropriate for the service provided (i.e., a code that most accurately represents the service provided), and not a code that is similar but represents another service. (CPT® Assistant, December 2010) Nonspecific or NOC codes may be subject to additional documentation requirements and review.

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five-digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

CPT codes for Joint Surgery

Note: Codes listed are in scope for joint surgery.

Shoulder Arthroplasty (Total/Partial/Revision Shoulder Replacement)
23470 Arthroplasty, glenohumeral joint; hemiarthroplasty
23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))
Shoulder Arthroscopy and Open Procedures
23105 Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy
23107 Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body
23120 Claviculectomy; partial
23130 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release
23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute
23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic
23415 Coracoacromial ligament release, with or without acromioplasty
23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)
23430 Tenodesis of long tendon of biceps
23440 Resection or transplantation of long tendon of biceps
23450 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation
23455 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)
23460 Capsulorrhaphy, anterior, any type; with bone block
23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer
23465 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block
23466 Capsulorrhaphy, glenohumeral joint, any type multidirectional instability
29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)
29806 Arthroscopy, shoulder, surgical; capsulorrhaphy
29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion
29819 Arthroscopy, shoulder, surgical; with removal of loose body or foreign body
29820 Arthroscopy, shoulder, surgical; synovectomy, partial
29821 Arthroscopy, shoulder, surgical; synovectomy, complete
29822 Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])
29823 Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])
29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)
29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation
29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)
29827 Arthroscopy, shoulder, surgical; with rotator cuff repair
29828 Arthroscopy, shoulder, surgical; biceps tenodesis
Hip Arthroplasty (Total/Partial/Revision Hip Replacement)
27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)
27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
Hip Arthroscopy
29860 Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure)
29861 Arthroscopy, hip, surgical; with removal of loose body or foreign body
29862 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum
29863 Arthroscopy, hip, surgical; with synovectomy
29914 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)
29915 Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)
29916 Arthroscopy, hip, surgical; with labral repair
Knee Arthroplasty (Total/Partial/Revision Knee Replacement)
27437 Arthroplasty, patella; without prosthesis
27438 Arthroplasty, patella; with prosthesis
27440 Arthroplasty, knee, tibial plateau
27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy
27442 Arthroplasty, femoral condyles or tibial plateau(s), knee
27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy
27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment
27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)
Knee Arthroscopy and Open Procedures
27331 Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies
27332 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral
27333 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral
27334 Arthrotomy, with synovectomy, knee; anterior OR posterior
27335 Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area
27403 Arthrotomy with meniscus repair, knee
27405 Repair, primary, torn ligament and/or capsule, knee; collateral
27407 Repair, primary, torn ligament and/or capsule, knee; cruciate
27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments
27427 Ligamentous reconstruction (augmentation), knee; extra-articular
27428 Ligamentous reconstruction (augmentation), knee; intra-articular (open)
27429 Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular
29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)
29871 Arthroscopy, knee, surgical; for infection, lavage and drainage
29873 Arthroscopy, knee, surgical; with lateral release
29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)
29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)
29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)
29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)
29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture
29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed
29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed
29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)
29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)
29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)
29885 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion)
29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion
29887 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation
29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction
29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction
Meniscal Allograft Transplantation of the Knee
29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral
Osteochondral Grafts
27412 Autologous chondrocyte implantation, knee
27415 Osteochondral allograft, knee, open
27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])
29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])
29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)
29892 Arthroscopically aided repair of large osteochondritis disssecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthoscopy)

CPT codes for Small Joint Surgery

27702 Arthroplasty, ankle; with implant (total ankle)
27703 Arthroplasty, ankle; revision, total ankle
27704 Removal of ankle implant
27870 Arthrodesis, ankle, open
28110 Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure)
28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)
28286 Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure)
28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant
28291 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant
28292 Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method
28295 Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method
28296 Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method
28297 Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method
28298 Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method
28299 Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with double osteotomy, any method
28306 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal
28307 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe)
28308 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each
28310 Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure)
28312 Osteotomy, shortening, angular or rotational correction; other phalanges, any toe
28315 Sesamoidectomy, first toe (separate procedure)
28750 Arthrodesis, great toe; metatarsophalangeal joint

CPT codes for Spine Surgery

Note: Codes listed are in scope for spine surgery.

Anterior Cervical Discectomy Fusion (ACDF) or Artificial Cervical Disc Arthroplasty
22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)
22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)
22634 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; each additional interspace (List separately in addition to code for primary procedure)
22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
22853 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)
22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical
22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)
Cervical Laminotomy/Laminectomy
63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical
63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)
63040 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical
63043 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure)
63048 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; each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)
63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace
63076 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)
63265 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical
Lumbar Discectomy/Laminectomy
63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis
63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)
63017 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar
63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar
63042 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar
63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure)
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
63048 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; each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)
63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)
63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)
63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar
Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)
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, lumbar
Vertebroplasty/Kyphoplasty
22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral
22512 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)
22513 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance
22514 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance
22515 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance

Appendix

ASA Physical Status Classification System

Classification Definition Adult examples, including, but not limited to:
ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use
ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease
ASA III A patient with severe systemic disease Substantive functional limitations; One or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥ 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (> 3 months) of MI, CVA, TIA, or CAD/stents.
ASA IV A patient with severe systemic disease that is a constant threat to life Recent (< 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
ASA V A moribund patient who is not expected to survive without the operation Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
ASA VI A declared brain-dead patient whose organs are being removed for donor purposes –

*The addition of “E” denotes Emergency surgery: (An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part)

Source: 2014 ASA Physical Status Classification System (Amended December 13, 2020) available at the American Society of Anesthesiologists website; Accessed March 3, 2022.

History

Status Review Date Effective Date Action
Reaffirmed 04/15/2024 Unchanged Independent Multispecialty Physician Panel (IMPP) review. Guideline reaffirmed. Removed “and Procedures” from the title. Added references.
Updated n/a 01/01/2024 Annual CPT code update. Description changes for 28292, 28295, 28296, 28297, 28298, 28299. Added guidance for correct coding to code section.
Revised 04/12/2023 11/05/2023 for commercial, Medicare and Medicaid except IA and LA; 04/14/2024 for IA Medicaid IMPP review. Added Total or partial primary shoulder arthroplasty for Ambulatory surgery center with 23-hour observation. Added Shoulder arthroplasty CPT codes: 23470 and 23472. Updated references. Added required language to General Clinical Guideline per new Medicare regulations.
Updated – 01/01/2023 2023 Annual CPT code update: description change for 22633.
Updated – 01/01/2022 2022 Annual CPT code update: description changes for 22633, 22634, 63048. Updated access date to ASA physical status chart.
Reaffirmed 11/11/2021 Unchanged IMPP review. Guideline reaffirmed.
Updated – 01/01/2021 2021 Annual CPT code update: description changes for 23466, 29822, 29823.
Revised 02/03/2020 11/01/2020 IMPP review. Added clarifications for thoracic and sacral spine. Added CPT codes for joint surgery: 27702, 27703, 27704, 27870, 28110, 28285, 28286, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28306, 28307, 28308, 28310, 28312, 28315, 28750, 29871, 29892. Added CPT codes for spine surgery: 22633, 22634, 63265, 63267.
Revised 07/11/2018 03/09/2019 IMPP review. Added the General Clinical Guideline.
Revised 07/11/2018 01/28/2019 IMPP review. Added observation surgical setting.
Created 12/12/2017 03/01/2018 IMPP review. Original effective date.

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