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At a Glance:
Title:
453-02-3359-m5
Date:
December 17, 2002

453-02-3359-m5

December 17, 2002

DECISION AND ORDER

This case concerns whether a neurosurgeon who performed diskectomy and fusion procedures on the claimant’s cervical spine can recover for: (1) “partial corpectomies”at three levels; and (2) preparation of graft material from a cadaver. The total amount at issue is $6,190.00.

The Administrative Law Judge (ALJ) concludes that the carrier is not required to reimburse the surgeon for corpectomies and preparation of graft material, but should pay for diskectomies at two levels.

I. Jurisdiction, Notice, and Procedural History

The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act (the Act). Tex. Lab. Code Ann. ch. 401 et seq. The State Office of Administrative Hearings (SOAH) has jurisdiction over this proceeding, including the authority to issue a decision and order. Tex. Lab. Code Ann. §413.031; Tex. Gov’t Code Ann. ch. 2003.

The Commission’s Medical Review Division (MRD) issued its decision May 14, 2002. Texas Mutual Insurance Company (TMIC) requested a hearing. Proper and timely notice of the hearing was issued June 20, 2002. The hearing was convened November 26, 2002, with ALJ Shannon Kilgore presiding. Patricia Eads appeared for TMIC, and Zahid Ansari appeared by telephone for Dr. Madhavan Pisharodi. The hearing was adjourned, and the record closed, the same day.

II. Evidence

The evidence in this case consists of:

  • the Commission’s certified record (TWCC Exhibit 1);
  • imaging studies of the claimant’s cervical spine (Carrier Exhibits A and B);
  • diagrammatic representations of cervical vertebrae (Carrier Exhibit C);
  • the videotaped deposition of Dr. Pisharodi (Carrier Ex. D);
  • Dr. Pisharodi’s surgical note from the claimant’s surgery (Carrier Exhibit D-1);
  • diagrams drawn by Dr. Pisharodi during his deposition (Carrier Exhibits D-2, D-3);
  • the videotaped deposition of Dr. Clark Watts, a neurosurgeon (Carrier Exhibit E);
  • the curriculum vitae of Dr. Watts (Carrier Exhibit F);
  • a letter by Dr. Pisharodi, dated November 25, 2002, commenting on Dr. Watts’ deposition (Provider Exhibit 1); and
  • the live testimony of Dr. N. Tsourmas, an orthopaedic surgeon called by TMIC to testify.

III. Facts

The claimant in this case, ________sustained a compensable injury on__________, while moving furniture.[1] She suffered from neck, shoulder, and chest pain. She was subsequently diagnosed with degenerative disc disease, including disc herniation or bulges at C4/C5, C5/C6, and C6/C7, as well as mild nerve root compression. TWCC Exhibit 1, p. 50.

Dr. Pisharodi performed surgery on June 21, 2001.[2] He generally described the surgery as “diskectomy, fusion and instrumentation.” Carrier Exhibit D-1, p. 1. He performed diskectomies of the C4/C5 and C5/C6 discs. After removing each disc, he removed a portion of the body of each vertebra surrounding the disc space, as well as any associated osteophytes. He characterized this removal of part of each of the C4, C5, and C6 vertebrae as “partial corpectomies.” Also, at each level, he inserted an allograft bone plug into the interspace, and packed any remaining space around it with bone chips. The bone grafts were to grow together, or “fuse”, with the surrounding vertebrae over time. Finally, a 44-millimeter titanium plate was positioned anteriorly and anchored by six screws - two at each level - inserted into the C4, C5, and C6 vertebrae. This use of the plate is characterized as “instrumentation.” See generally, id.

Dr. Pisharodi billed as follows for the surgery on June 21, 2001:

  • application of cranial tongs, caliper, or stereotactic frame (CPT Code 20660);
  • fluoroscopy (CPT Codes 76000, plus two units of CPT Code 76001);
  • cervical vertebral corpectomy, partial or complete, single segment (CPT Code 63081);
  • cervical vertebral corpectomy, partial or complete, each additional segment (CPT Code 63082) (two units);
  • anterior instrumentation (CPT Code 22845);
  • arthrodesis,[3] anterior interbody technique, cervical below C2, with bone graft (CPT Code 22554);
  • arthrodesis, each additional interspace (CPT Code 22585); and
  • bone graft, major or large (CPT Code 20902).

TWCC Exhibit 1, pp. 13 - 14. TMIC reimbursed Dr. Pisharodi for CPT Codes 22845, 22554, 22585, and 20660. Id., p. 21. The carrier’s explanation of benefits stated that the documentation did not support the bills for corpectomies (CPT Codes 63081, 63082), and that the bone graft (CPT Code 20902) was not reimbursable as billed.[4] Id.

Dr. Pisharodi sought reconsideration of the denial of payment for the corpectomy and bone graft codes, which was denied by TMIC. Id., pp. 26 - 27. Dr. Pisharodi appealed to the MRD, which determined that the operative report substantiated the services billed. The MRD ordered payment of $6,190.00.

IV. Discussion

Three partial corpectomies (CPT Codes 63081, 63082

The parties largely agree on what Dr. Pisharodi did in the claimant’s surgery on June 21, 2001. They disagree about how to characterize the surgical procedures for billing purposes.

TMIC’s view, expressed through the testimony of Drs. Watts and Tsourmas, is that Dr. Pisharodi performed a valid, and quite standard, surgery that has been routinely done for many years. These doctors testified that the chief purposes of this kind of surgery are to remove discs that are herniated or bulging, replace them with bone graft material that will fuse with the surrounding vertebrae, and stabilize the area with a metal plate anchored into the bone with screws. According to these surgeons, the removal of a small portion of the vertebrae surrounding the interspaces from which the discs have been excised is a necessary part of the overall procedure, for two primary reasons. First, it is necessary to remove some of the body, or “corpus”, of each vertebra in order to make room for the bone graft that will be inserted into the interspace. Second, to promote fusion of the graft with the surrounding bone, the surgeon must “rough up” the edges of the vertebrae to expose raw, bloody bone material.

Drs. Watts and Tsourmas testified that “corpectomy” means removal of part or all of the corpus of the vertebra, but that it is not appropriate to bill for a corpectomy - or even a “partial corpectomy” - when a surgeon merely takes a relatively small amount of the corpus in the context of a fusion operation. They stated that a true “corpectomy”, as the term is usually used, involves removing a larger portion of the corpus for reasons not present in this case (such as to accommodate an exceptionally large graft, or in cases of fracture or infection of the corpus, or in cases involving such a complete collapse of the disc space that the corpus itself compresses the spinal cord). Both doctors testified that they had never seen an ordinary diskectomy and fusion operation billed to include corpectomies.

Dr. Pisharodi stated that he removed a substantial portion of the corpus of each of three vertebrae, and that his technique can be characterized as a “partial horizontal corpectomy” that removes part of the corpus as well as osteophytes. He noted that Dr. Watts said in his deposition that the removal of even a small amount of the corpus could technically be considered a corpectomy.

The ALJ determines that this surgery is not appropriately characterized as involving “partial corpectomies.” The ALJ is persuaded by the testimony of Drs. Watts and Tsourmas that this was a fairly routine operation for which billing practices are well-established, that they have never seen any other surgeon bill this way, and that the removal of part of the vertebrae in this surgery was necessary to the diskectomy and fusion procedures. Dr. Pisharodi is, therefore, not entitled to recover for the “partial corpectomies”

The ALJ notes, however, that Dr. Pisharodi apparently billed for three corpectomies in lieu of billing for two diskectomies. While the parties did not address this issue directly, it appears that Dr. Pisharodi is entitled to be reimbursed for the first diskectomy (CPT Code 63075 - diskectomy, anterior, with decompression of spinal cord and/or nerve roots, including osteophytectomy), plus one additional interspace (CPT Code 63076). The total maximum allowable reimbursement for these two procedures is $3,439.00 (as opposed to $5,664.00 under the corpectomy codes).

Bone graft (CPT Code 20902

The ALJ determines that the use of cadaver material in a fusion operation is global to the fusion procedure. First, it appears that CPT Code 20902 is intended to be used when bone is harvested from the patient through a separate incision; the descriptions of the procedures under that section of the Medical Fee Guideline, which relate to musculoskeletal system grafts, refer to donor sites or harvesting techniques. Second, the code used by Dr. Pisharodi for the fusion procedures, CPT Code 22554, indicates that it includes a “bone graft” component.

Since Dr. Pisharodi did not have to expend any time or effort in surgery harvesting the graft material, and the insertion of the graft material is part of the fusion procedure, the ALJ concludes that Dr. Pisharodi should not be reimbursed for CPT Code 20902.

V. Findings of Fact

  1. The claimant in this case, ____sustained a compensable injury on_________, while moving furniture. She suffered from neck, shoulder, and chest pain.
  2. The claimant was subsequently diagnosed with degenerative disc disease, including disc herniation or bulges at C4/C5, C5/C6, and C6/C7, as well as mild nerve root compression.
  3. The workers’ compensation carrier for claimant’s employer is Texas Mutual Insurance Company (TMIC).
  4. Dr. Madhavan Pisharodi, a neurosurgeon, performed surgery on the claimant on June 21, 2001.
  5. In the surgery, Dr. Pisharodi performed diskectomies of the C4/C5 and C5/C6 discs. After removing each disc, he removed a portion of the body of each vertebra surrounding the disc space, as well as any associated osteophytes. He billed this part of the operation under CPT Codes 63081 and 63082 (corpectomies) (2 units).
  6. Also, at each level, Dr. Pisharodi inserted an allograft bone plug (from a cadaver) into the interspace, and packed any remaining space around it with bone chips. He billed this part of the operation under CPT Codes 22554 and 22585 (“arthrodesis” or fusion) and 20902 (bone graft).
  7. The carrier’s explanation of benefits stated that the documentation did not support the bills for corpectomies (CPT Codes 63081, 63082), and that the bone graft (CPT Code 20902) was not reimbursable as billed.
  8. Dr. Pisharodi sought reconsideration of the denial of payment for the corpectomy and bone graft codes, which was denied by TMIC.
  9. Dr. Pisharodi appealed to the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission).
  10. The MRD issued its decision May 14, 2002. The MRD determined that the operative report substantiated the services billed, and ordered payment of $6,190.00.
  11. TMIC requested an appeal of the MRD decision.
  12. Notice of the hearing was issued June 20, 2002.
  13. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  14. The hearing was convened November 26, 2002, with Administrative Law Judge Shannon Kilgore presiding. Patricia Eads appeared for TMIC, and Zahid Ansari appeared by telephone for Dr. Pisharodi. The hearing was adjourned, and the record closed, the same day.
  15. In this cervical diskectomy and fusion operation, the removal of portions of the vertebrae surrounding the interspaces from which the discs had been excised was a necessary part of the fusion procedure. It was necessary to remove some of the body, or “corpus”, of each vertebra in order to make room for the bone graft that was to be inserted into the interspace. Also, to promote fusion of the graft with the surrounding bone, the surgeon had to “rough up” the edges of the vertebrae to expose raw, bloody bone material.
  16. It is not customary to bill for corpectomies in connection with the kind of surgery Dr. Pisharodi performed on the claimant on June 21, 2001.
  17. The removal of part of the corpus of each of the C4, C5, and C6 vertebrae was part of the diskectomy and fusion procedures.
  18. Dr. Pisharodi should have billed under CPT Codes 63075 and 63076 (diskectomies at the C4/C5 and C5/C6 levels and removal of associated osteophytes), for a total allowable recovery of $3,439.00.
  19. The claimant’s operation did not involve the harvesting of any autograft material.
  20. CPT Codes 22554 and 22585 cover the fusion procedures Dr. Pisharodi performed, including the placement of graft material.

VI. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to § 413.031 of the Texas Workers' Compensation Act (the Act). See Tex. Lab. Code ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order in this case. Tex. Lab. Code Ann. § 413.031; Tex. Gov’t Code ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with the Texas Administrative Procedure Act. Tex. Gov’t Code § 2001.052.
  4. TMIC has the burden of proof in this matter. 28 TAC § 148.21(h).
  5. Based on Findings of Fact 4 - 6 and 15 - 17 and pursuant to the Medical Fee Guideline, Dr. Pisharodi should not be reimbursed under CPT Codes 63801 and 63802
  6. Based on Finding of Fact 18, Dr. Pisharodi should be paid $3,439.00 for diskectomies at the C4/C5 and C5/C6 levels and removal of associated osteophytes.
  7. Based on Findings of Fact 19 and 20 and pursuant to the Medical Fee Guideline, Dr. Pisharodi should not be reimbursed under CPT Code 20902.

ORDER

IT IS, THEREFORE, ORDERED that Texas Mutual Insurance Company reimburse Madhavan Pisharodi, M.D., $3,439.00 for diskectomies performed in connection with the workers’ compensation claimant’s surgery on June 21, 2001.

Signed this 17th of December, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Shannon Kilgore
Administrative Law Judge

  1. The record includes a neurosurgeon’s opinion that the claimant’s neck pain, cervical radiculopathy, and cervical degenerative disk disease were not related to her________ , injury. TWCC Exhibit 1, pp. 58 - 61. However, TMIC has not contested the relationship of the surgery at issue in this case to the compensable injury.
  2. Prior to the surgery, Dr. R.N. “Adobbati provided a second opinion expressing agreement with Dr. Pisharodi’s recommendation for diskectomy with anterior fusion and instrumentation. TWCC Exhibit 1, pp. 49 - 50.
  3. “Arthrodesis” refers to the surgical immobilization of a joint, or in this case the fusion procedures.
  4. TMIC also stated that reimbursement for the fluoroscopy codes (76000, 76001) was global to the surgical procedures. TWCC Exhibit 1, pp. 21, 26. The fluoroscopy codes, however, are not at issue in this case.
End of Document
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