Full statement from Julie Knutson, counsel for Regional West Health Services, where Dr. Jimenez works

Statement from Julie Knutson, Counsel for Regional West Health Services

March 25, 2014

VIA ELECTRONIC MAIL

Mr. Benjamin Eisler

Producer, CBS News

Ben,

This responds to your request for information regarding spinal fusion surgeries performed for Medicare patients by Omar Jimenez, M.D., for calendar years 2011 and 2012. You provided some background information which we understand was obtained via Freedom of Information Act ("FOIA") request from the Centers for Medicare and Medicaid. You stated that, according to your information, Dr. Jimenez performed more than 300 lumbar fusions during the period beginning January 1, 2011 and ending December 31, 2012. You also stated that these surgeries were performed for reasons other than deformity, tumor, fracture or infection. In subsequent e-mail discussion, you also provided the following additional information: the report identified by CPT code (with modifiers) spinal fusion surgeries for codes 22558, 22585, 22586, 22612, 22614, 22630, 22632, 22633 and 22634. ICD-9 ( (diagnosis codes) were not requested. According to your emails, the CPT codes intended for deformity, tumor, fracture and infection were excluded from your request but we do not know exactly which codes you included in the list of excluded procedures.

You declined to provide a copy of the report on which your query is based, so we have a disadvantage in responding. Your question suggests that all medically necessary diagnoses are represented by separate series of CPT codes and, by excluding from the FOIA request those codes associated with specific diagnoses, the procedures that remain (as represented by other spinal surgery codes) are of questionable medical necessity. This is an incorrect and misleading statement that is not consistent with either clinical practice or recognized coding guidance.

To begin with, only the following CPT codes for spinal surgery denote specific medical conditions: (i) deformity (22800 series); (ii) fracture (22318-22328); (iii) decompression of the spine following fracture (63001-63091) and (iv) arthrodesis of the spine following fracture (22548-22632). All other medically appropriate reasons for performing spinal fusion surgery are represented by CPT codes series which focus on the surgical route of entry, the section of the spine and the number of vertebrae or spaces involved in the surgery or the nature of the procedure.

Also, please note there is a general rule of coding that, when two codes are potentially appropriate, the most specific or descriptive code should be used. In cases of staged surgeries (using modifier "58" ) and others, the most descriptive code may be the "general" spinal fusion codes in concert with modifiers, as explained. The following guidance for coders regarding arthrodesis (fusion) is set out in the AANS Coding Manual and the Ortho Coding Companion as well as the CPT Assistant, all recognized coding reference manuals:

"Arthrodesis for spinal deformities such as scoliosis or kyphosis are reported using codes 22800-22812. If the arthrodesis is being performed for a reason other than to correct a spinal deformity, then the codes used to report arthrodesis are classified by anatomical approaches (22548-22650) [anterior or anterolateral approach, posterior or posterolateral approach, or anterior or posterior interbody technique]."

Thus, the proper code for surgery to treat degenerative scoliosis is one of the codes for the anatomical approaches, not the spinal deformity codes. This means that, to conclude the spinal fusion surgeries performed by Dr. Jimenez coded under the codes series 2258_, 2261_ and 2263__ did not reflect surgeries for patients with a diagnosis of spinal deformity, tumor, fracture or infection is an incorrect conclusion based on faulty assumptions about the FOIA data. It is simply not possible to discern the diagnosis(es) from the CPT code alone.

In addition, complex and lengthy spinal surgeries may be "staged," that is, conducted on separate days, because the patient's condition requires a surgical approach from two aspects (front, back and/or side). Shorter spinal segments with complicated anatomy, as well as patients who have had previous surgery with scarring may also be managed this way, possibly with the surgeries being performed on the same day (modifier 59). These are well-established and acceptable approaches for treating complex spinal conditions that are used by both neurosurgeons and orthopedic spine surgeons.

However, if multiple vertebrae are involved or the patient has significant co-morbidities, performing both surgical approaches on the same day would be unduly risky for the patient, e.g., blood loss, the period of time under anesthesia, and increased risk of infection in repositioning the patient for a second surgery and exchanging equipment. For these complex staged operations on separate days, the time between the surgeries allows recovery of the patient's medical state from the blood loss and normalization of blood pressure. It decreases the risk of infection due to shorter procedures and less "open" time and permits better pain control as the patient can be pretreated with painkillers before the second procedure. In staged procedures conducted on different days, the two CPT codes denoting the different surgical entries are appended by modifier 58 to show that the pre-planned, staged surgeries were performed for the same patient on different dates. While these are, for some purposes treated as separate procedures, it would not be accurate to characterize staged procedures as separate surgical events for different patients.

It is also clinically inaccurate to suggest that that deformity, fracture, tumor or infection are the only medically appropriate reasons for performing a spinal fusion. Other possible indications include but are not limited to: degenerative scoliosis, spondylolisthesis with instability, isthmic spondylolysis (pars defect); multiple recurrent discs recalcitrant to conservative treatments, adjacent level disease, pseudo arthrosis, intraoperative findings of instability, previous laminectomy where adequate decompression requires creating of a pars defect or removal of either 75% of one facet or greater than 50% of both facets.

Finally, we point out that Dr. Jimenez's practice situation is unique and likely contributes to the number of patients that he treats. The Medical Center at Scottsbluff, Nebraska, is a regional referral center with Level II trauma certification. Dr. Jimenez is an employee of Regional West Physicians Clinic, which is a sister corporation of Regional West Medical Center. The combined service area of the Medical Center is 19 counties in western Nebraska as well as northeast Colorado, eastern Wyoming and southwestern South Dakota. The Medical Center also operates a 20-bed acute rehabilitation unit and a medical air/ground ambulance service. The next closest tertiary facilities that perform spinal surgery with surgeons other than Dr. Jimenez are located in Casper, Wyoming (176 miles), Cheyenne, Wyoming (112 miles), Denver, Colorado (210 miles), Fort Collins, Colorado (156 miles), Greeley, Colorado (160 miles), Rapid City, South Dakota (194 miles) and Kearney, Nebraska (272 miles). Dr. Jimenez is the only neurosurgeon practicing at the Medical Center as well as at Great Plains Regional Medical Center in North Platte, Nebraska, 176 miles to the east. Patients in the service area also include those who live in North Platte, Nebraska but who received surgery from Dr. Jimenez in Scottsbluff.

Dr. Jimenez is well aware of and shares the general concern about unnecessary spinal surgeries and follows a multi-step process involving less invasive interventions and extensive multidisciplinary evaluation including imaging studies before recommending surgery to his patients. Before a fusion is considered, he treats his patients conservatively with a course of care that might include NSAIDs, physical therapy and injections.

Thank you for this opportunity to respond in writing.

Omar Jimenez, M.D.

Regional West Physicians Clinic

DOCS/1249372.2