The following information may be useful to physicians submitting claims for the IDET* procedure:
Physicians’ Current Procedural Terminology (CPT), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures physicians and other medical professionals perform.
- The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, thereby serving as a means for standardized communication among physicians, patients and third parties.
- HCFA-1500 claims for physician services and UB-92 claims for hospital outpatient procedures must contain appropriate CPT codes.
Modifiers indicate that a service was altered in some way from the stated CPT descriptor without changing the definition. The American Medical Association (AMA) CPT modifiers are 2-digit numeric codes listed after a procedure code and separated from the CPT code by a hyphen. The following CPT modifiers may be relevant to the IDET procedure:
| CPT Modifier | Description |
| -53 | Discontinued Procedure (HCFA-1500) |
| -73 | Discontinued Out-Pt/ASC procedure before Anesthesia administered (UB-92) |
| -74 | Discontinued Out-Pt/ASC procedure after Anesthesia administered (UB-92) |
Medicare policy specifies that payment for physician services is based on the lesser of the actual charge or a payment amount computed under the physician fee schedule.
- Payment amounts for specific services under the physician fee schedule are computed as the product of three factors:
- Relative value unit (RVU) for the service
- Geographic adjustment (GAF) for the fee schedule area
- A nationally uniform dollar conversion factor (CF)
- The actual amount paid by Medicare to participating physicians is 80% of the fee schedule, or their actual charge, whichever is lower. Physicians are permitted to bill the Medicare beneficiary and/or secondary carrier for the remaining 20%.
- Non-participating physicians must collect their fee directly from the Medicare beneficiary. The physician may bill the beneficiary and/or secondary carrier up to a “limiting charge” of 115% of the non-participating fee schedule amount. Medicare will directly pay the Medicare beneficiary 80% of the fee schedule amount.
| CPT Code | Description | Non-facility | Facility |
| 22526 | Percutaneous electrothermal intradiscal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level | $2,027.75 | $326.02 |
| 22527 | One or more additional levels (List separately in addition to 22526 for primary procedure) | $1,662.50 | $150.44 |
All claim forms must use ICD-9-CM diagnosis codes to report the patient’s condition. These codes reflect the physician’s assessment of a particular patient’s condition. The following diagnosis codes may apply to patients undergoing the IDET procedure and should be used only if they describe a patient’s condition accurately:
| ICD-9 | Description | CPT Cross Reference |
| 722.1 | Displacement of lumbar intervertebral disc without myelopathy | 22526, 22527 |
| 722.7 | Intervertebral lumbar disc disorder with myelopathy, lumbar region | 22526, 22527 |
| 722.9 | Other and unspecified disc disorder of lumbar region | 22526, 22527 |
| 724.2 | LUMBAGO | 22526, 22527 |
| 724.4 | LUMBOSACRAL NEURITIS NOS | 22526, 22527 |
| 724.5 | BACKACHE NOS | 22526, 22527 |
Private insurers have varying payment guidelines, especially regarding new procedures. Typically they base payment on charges, discounted charges, fee schedules, or capitation.
- Payment amounts will vary based on contractual arrangements with the individual payors. Due to these arrangements, the insurer should be contacted for their specific payment guidelines regarding the IDET procedure.
- Cautionary Note: Many third-party payors require prior authorization before paying for a new procedure and will generally deny reimbursement if such approval is not received in advance.
For further help with insurance and reimbursement, use our Reimbursement Calculation Tools.