Tuesday, December 1, 2009

XLIF: A Point of Clarification

In retrospect, TSB has had the opportunity to discuss the content of the NuVasive Investors Conference Call. Here are some observations by TSB. If an XLIF is coded as an ALIF, is it the appropriate code to get properly reimbursed? If one adheres to the code established by NASS, the answer is yes. Lukianov was quick to point out the this is not a problem on the national level, but a problem on the local level. So how do surgeons dictate their post-op notes after performing an XLIF? Are they apt to ramble on?

In all likelihood, if the surgeon is dictating that they had performed an XLIF, which would be appropriate, and the payors are scrutinizing the operative notes, don't the codes need to match the procedure? So in the spirit of debate is it an ALIF, or, is it an XLIF? Herein lies the problem! If the surgeon dictates that an ALIF was performed, when in fact an XLIF was performed, would that constitute fraud?

Another point of clarification is that the amount a surgeon is reimbursed for a true ALIF is different than what a surgeon is reimbursed for an XLIF. In an ALIF, there is usually an Access Surgeon whether it be a General or Vascular Surgeon. In all likelihood the primary attending is splitting some percentage of the reimbursement with the access surgeon. Isn't that how NuVasive originally marketed this product? That you would no longer need an Access Surgeon and that the procedure was safer? TSB has the utmost respect for anyone as successful as NuVasive, yet, one has to wonder whether or not some of this commentary was factually correct?

Confusion? Maybe? Could be where the problem lies with the payors. TSB wants to know what our readers think?


  1. XLIF should be dictated as a "Anterior Column lumbar surgery from a anterolateral approach." When done this way, there should be no issues. Codes match dictation and no fraud is committed. XLIF is a brand, not a procedure.

  2. Anterolateral approach is at a 30 to 45 degree angle and still through an anterior incision. While XLIF is a brand, it is also the name of the procedure - extreme lateral interbody fusion - hence the name says it is a different approach then ALIF. Medtronic's system is called DLIF - Direct Lateral interbody fusion, again this is a different approach then an ALIF. We all know that using ALIF codes is a play on words or is at best the code that is the closest to describing XLIF. The other issue is that surgeons are abusing the code and reimbursement by doing interbody and then doing a facet dowl or interspinous clamp and calling it a posterior fusion so they can bill for a 360. They are not doing the work they are billing for and are not spending the time (RVUs) that the reimbursement was established for.
    Nuvasive has done a great job showing surgeons how they can maximize their reimbursement and make the most money possible, despite what is best for the patient. One example was their brochure they put out on how to increase your practices revenue by $100k by monitoring all your cases and billing for it. Now they have their handheld device that another surgeon can use to monitor your case while he is doing clinic. Now you both can bill for monitoring review on each other cases. If this does not smell fishy or seem at all negligent to patient care, then I guess we all just became Neurologists.

  3. What brouchure are you talking about with regards to the $100k? Is that postable?