WorkSafe spinal surgery billing position statement

Billing guidelines for common spinal surgical procedures with the 1 November 2018 spinal surgery Medicare Benefits Schedule (MBS).

Preamble

WorkSafe Victoria (WorkSafe) can pay the reasonable costs of medical services provided by a medical practitioner to an injured worker where required as a result of a work-related injury or illness.

WorkSafe adopts the Medicare Benefits Schedule (MBS) item numbers, explanations, definitions, rules and conditions for services provided by medical practitioners. When invoicing for medical services, medical practitioners are expected to adhere to these MBS explanations, definitions, rules and conditions unless otherwise specified by WorkSafe in this publication or its medical policies.

On 1 July 2019 WorkSafe (Victoria) adopted the new MBS for Spinal Surgery schedule for the invoicing of all spinal surgical procedures.

This publication outlines WorkSafe's position for appropriate item number usage for implementation of the new MBS for Spinal Surgery, and replaces the previous Position Statement of November 2018. It has been developed based on recommendations from Spinal Surgeons on WorkSafe's Surgery Advisory Panel (SAP), independently of the associated fee schedule.

This publication will be reviewed and updated regularly in line with MBS updates and must be read in conjunction with:

  • the Medicare Benefits Schedule (MBS)
  • Department of Health Spine Surgery Case Example Guide
  • WorkSafe's Reimbursement Rates for Medical Services
  • WorkSafe's medical practitioner and elective surgery policies
  • other health professional policies on our website

Where there are differing interpretations of the MBS rules pertaining to item number usage (or the MBS rules are insufficiently clear), this document acts to clarify WorkSafe's position on what it considers is appropriate item number use.

WorkSafe periodically reviews payments for surgical services to ensure that they are appropriate and comply with the MBS and relevant WorkSafe policies and guidelines. As a result of these reviews, WorkSafe may seek reimbursement of any amount deemed to be overpaid.

General Guidelines for billing of spinal surgical procedures funded by WorkSafe (Victoria):

  1. All spinal surgical procedures must be billed (and described) from within the new MBS section for Spinal Surgery (i.e. there should be no item numbers included from other sections of the MBS when billing for spinal surgery).
  2. In general, the 'explanations, definitions, rules and conditions' associated with the new MBS for Spinal Surgery will apply, unless otherwise specified by WorkSafe in this publication.
  3. These Guidelines contain further clarification of the rules of the new MBS for Spinal Surgery, as interpreted by the SAP, for common spinal surgical procedures funded by WorkSafe (Victoria).
  4. If, after the surgery is completed, the surgeon considers that there are exceptional circumstances to justify variance from these Guidelines, the surgeon can submit detailed reasoning supported by documentation which should include a contemporaneous legible operation note and any routinely performed imaging (the relevant imaging series on a CD/DVD, including unedited pre-operative and routine post-operative imaging). The SAP will consider these applications for variance and advise on whether the requested additional item numbers (or other item numbers) are acceptable.
  5. The Spinal Surgery item numbers are organised into eight categories:

    Cat. 1 Spinal Decompression - 51011 to 51015

    Cat. 2 Spinal Instrumentatio - 51020 to 51026

    Cat. 3 Posterior and/or Posterolateral Fusion - 51031 to 51036

    Cat. 4 Interbody (anterior column) Fusion - 51041 to 51045

    Cat. 5 Spinal Osteotomy and/or Vertebrectomy - (See guideline 13)

    Cat. 6 Combined Anterior and Posterior Fusion - 51061 to 51066

    Cat. 7 Intradural Procedures - (See guideline 14)

    Cat. 8 Miscellaneous Procedures - 51102 to 51171

  6. As per the MBS : 'From within each of these categories only the single most appropriate item number can be claimed'. WorkSafe takes the view that, for an item number to be used, the services specified in the associated descriptor must be wholly or substantially undertaken (i.e. it is inappropriate to use an item number because 'technically' a minor part of the services described by that item number were undertaken). This particularly applies to segments and posterolateral lumbar fusions. For example, exposure or probing of a spinal segment adjacent to the pathological segment does not qualify for more than decompression at the pathological segment(s), and the placement of locally harvested bone or bone substitute adjacent to a lumbar facet joint without exposure and decortication of the transverse processes does not qualify for a posterolateral lumbar fusion.
  7. For (direct) decompressive surgery without instrumentation and/or fusion (e.g. lumbar microdiscectomy/discectomy or lumbar decompression laminectomy +/- foraminotomy), one item number should be used from Cat. 1 (only). Requests for decompressive spinal surgery should be described per segment (not per nerve root) and, where this is not adequately specified/justified, it will be interpreted that the decompression is being performed only at the segment where there is pathological compression.
  8. For surgery which includes an interbody fusion (by an approach which routinely involves direct operative decompression, i.e. surgical access to a substantial portion of the nerve root exit foramen or spinal canal) (e.g. ACDF and PLIF, but not ALIF or XLIF/OLIF), one item number from Cat. 4 can be added to one item number from Cat. 1.
  9. For anterior lumbar interbody fusion (ALIF, including XLIF/OLIF) it is inappropriate to use an item number from Cat. 1, and this will not be paid.
  10. If segmental internal fixation is undertaken, one item number from Cat. 2 should be added.
  11. If a posterolateral or posterior fusion (i.e. lumbar intertransverse fusion or cervical facet joint fusion) is undertaken, one item number from Cat. 3 should be added.
  12. Item numbers from Cat. 3 will not be paid without specification (i.e. will not be assumed under the general descriptor of "fusion", see point 31) and will be only be paid for lumbar or thoracic intertransverse posterolateral fusion or cervical facet joint fusion where significant added surgical time/effort is required for the performance of the Cat. 3 surgery (e.g. will not be paid for using bone, bone substitutes or BMPs around or in lumbar facet joints or lamina while undertaking a posterior lumbar interbody fusion).
  13. Item numbers from Cat. 5 (pedicle subtraction osteotomy and vertebrectomy) will not be paid without convincing explanatory exceptional circumstances.
  14. Item numbers from Cat. 7 (intradural procedures) will not be paid without convincing explanatory exceptional circumstances.
  15. The item numbers pertaining to surgical management of spinal fractures will be funded according to the surgical procedure performed using the Spinal Surgery section of the MBS (rather than using the fracture section of the MBS).
  16. If autogenous bone graft is harvested from a separate non-spinal surgical site (as per the descriptor for item number 51120) for any spinal fusion, item number 51120 can be added, but this does not apply for locally harvested bone fragments from the spine or for the use of BMPs alone. It is increasingly rare for this item to be appropriately used in current routine spinal surgery.
  17. An assisting (access) surgeon undertaking the anterior exposure of the lumbar spine should use item number 51160, if for exposure of 1 spinal segment, or item number 51165, if for exposure of more than 1 spinal segment. These item numbers cannot be combined with item numbers from any other section of the MBS.
  18. If there is an unexpected complication of the anterior exposure of the lumbar spine (i.e. not part of the routine exposure surgery) sufficient to use item numbers from another section of the MBS (e.g. the vascular section), item numbers 51160 or 51165 cannot be used.
  19. If the spinal surgeon undertakes the anterior exposure of the lumbar spine (without an assisting access surgeon), item number 51160 or 51165, as appropriate, can be added to the other Spinal Surgery item numbers used by the spinal surgeon.
  20. Cervical TDR (item number 51131) can be combined with an item number from Cat. 1, if the surgery involves direct decompression of the nerve root exit foramen or spinal canal, at that level.
  21. Lumbar TDR (item number 51130) cannot be combined with an item number from Cat. 1 (because the decompression is indirect), and this will not be paid.
  22. The service of cervical TDR (item number 51131) and lumbar TDR (item number 51130) includes fixation of the TDR device. The use of Cat. 2 item numbers is not appropriate at the segments where TDR is performed, and Cat. 2 item numbers including the TDR segment will not be paid.
  23. In the case of combined anterior and posterior spinal fusion surgery which is completed as part of one anaesthetic (e.g. ALIF with pedicle screws), one item number from Cat. 6 can be used - and one item number from Cat. 1 could be added, if applicable (e.g. if a decompression laminectomy was performed), but item numbers from Cat. 2, 3 or 4 cannot be added.
  24. If, in exceptional circumstances, the anterior and posterior components of a combined anterior and posterior spinal fusion procedure are undertaken as part of two anaesthetics on different days (a staged procedure), only the item numbers relevant to the components of the surgery undertaken at each stage can be billed for each procedure (from Cat. 1, 2, 3 or 4) without any duplication of item numbers across the 'stages' [i.e. a decompression item number (Cat. 1) can only be billed once even if a decompression is undertaken at each stage and a fixation item number (Cat. 2) can only be used once even if fixation is applied both anteriorly and posteriorly at one segment]. Cat. 6 item numbers cannot be used in this circumstance.
  25. Any planned staged procedure, including the above example, will be treated as one procedure with respect to the use of item numbers. This includes the use of step-downs when billing for multiple item numbers.
  26. There is no additional or differentiating item number for surgery for recurrent disc lesion;
  27. In the case of revision of previous spinal fusion surgery, without requiring adjustment or removal of instrumentation, only the appropriate item numbers for the components of the surgery (from Cat. 1, 2, 3, 4 & 6) are used.
  28. In the case of revision of previous spinal fusion surgery, requiring adjustment or removal of instrumentation, item numbers 51140 or 51141 (as appropriate) are combined with the appropriate item numbers for the other components of the surgery (from Cat. 1, 2, 3, 4 & 6).
  29. In the case of "hybrid" fusion/TDR surgery, the item numbers for the various components of the surgery should be applied without using more than one item number from Cat. 2, 3 and 4, or 6 (as appropriate) and Cat. 1 (if appropriate) - but multiple item numbers can be used from Cat. 8 - as appropriate for the descriptors and the applicable rules.
  30. The use of BMPs without combination with bone or bone substitutes does not satisfy the requirements for use of item numbers in Cat. 3, 4 and 6.
  31. When submitting item numbers for approval (and for postoperative substantiation of item numbers), there needs to be sufficient detail in the material provided by the surgeon to clearly establish that the component item numbers are appropriate. It is insufficient to list the item numbers with the MBS descriptor verbatum. The simplest and quickest way is to provide an operation title with sufficient detail for the medical advisors to approve the item numbers without needing to delay the process by further requests for clarification or SAP review.

Common operations by primary title (or description by requesting surgeon)