Comparison of Recent Trends in Medicare Utilization and Reimbursement for Anterior Cervical Spine Discectomy and Fusion as Compared to Cervical Disc Arthroplasty

Abstract

Study Design

Retrospective Database Study.

Objectives

Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are common procedures performed for cervical spondylosis. Sparse data exists comparing the utilization and reimbursement rates associated with these procedures. This study seeks to compare Medicare utilization of single- and multilevel ACDF to CDA between 2011 and 2021. Additionally, this study evaluates Medicare reimbursement rate changes for ACDF with structural allograft, ACDF with cage, and CDA between the years 2016 and 2021.

Methods

This study used the publicly available Medicare National Summary Data Files to aggregate annual utilization and reimbursement rates for ACDF procedures as well as CDA procedures based on Current Procedural Terminology codes. Reimbursement rates were adjusted for inflation through use of the U.S. Bureau of Labor Statistics’ 2021 Consumer Price Index. Changes in reimbursement rates and utilization were calculated and compared between procedures.

Results

In 2011, 27 974 single-level ACDF procedures were performed on Medicare Part B patients compared to 34 683 performed in 2021. This represents a growth in procedure utilization of 24% over the study period. Over the course of the same study period CDA procedures grew by 1087.3%, from 118 in 2011 to 1401 in 2021. Throughout the reimbursement study period, Medicare reimbursements per case for single-level CDAs had an average annual percent change of 9.96%, rising from $1636 in 2016 to $2779 in 2021. Reimbursement per case for single-level ACDF with allograft had an average annual change of −1.25%, falling from $3408 in 2016 to $3206 in 2021. Medicare reimbursement per case for single-level ACDF with cage had an average annual change of 1.19%, from $3379 in 2017 to $3547 in 2021.

Conclusion

All procedures saw an increase in utilization throughout the study period, with CDAs showing significant growth within the Medicare population. While the reimbursement for ACDFs remained relatively constant, the reimbursement for CDAs demonstrated a moderate increase.

Keywords

anterior cervical discectomy and fusion cervical disc arthroplasty medicare procedure reimbursement procedure utilization cervical spine

Introduction

Degenerative disc disease of the cervical spine is most commonly associated with the aging process, as age-related changes in spinal mechanics and anatomy alter normal function. While the most common symptom is neck pain, in more serious cases patients can experience radiculopathy, parathesis, myelopathy, and, eventually, paralysis.¹ Patients without significant neurologic insult are treated conservatively with analgesics, corticosteroids, neck immobilization, traction of the cervical spine, physical therapy, targeted exercises, thermal therapy, and avoidance of provocative activities.² When patients have persistent neurologic symptoms or become myelopathic, surgical decompression of either the symptomatic nerve root, the spinal cord, or both simultaneously is considered first line treatment.³

ACDF and CDA have both proven effective in treating cervical spine pathology. More recently, CDA has seen an increase in popularity as compared to ACDF.⁴ A better understanding of the utilization and payments associated with anterior-based cervical spine decompression procedures within the Medicare system may help identify key trends in delivering safe and cost-effective patient care. Through investigation of these Medicare trends, we can gain valuable insight into patient care and preferred treatment options given the changing landscape in healthcare utilization and value-based care. The purpose of this study is to compare the trends and variations in the utilization for ACDF and CDA in the Medicare system between 2011 and 2021, and the trends and variations in reimbursements between 2016 and 2021.

Materials and Methods

This study was exempt from institutional review board approval as no patient information was employed.

Data Source

The publicly available Medicare Part B National Summary Data Files (previously known as BESS) from the years 2011 to 2021 served as the source for this study. The database was queried for annual incidence of procedures by procedure code. The Current Procedural Terminology (CPT) codes included in this analysis are as follows: 22 551 (single-level anterior fusion and discectomy, ACDF), 22 552 (multilevel ACDF), 22 856 (single-level total disc arthroplasty, CDA), and 22 858 (multilevel CDA). Reimbursement data was collected from the years 2016 to 2021. While CDA is a bundled procedure, an ACDF is typically billed by combining codes based on the implants utilized. To account for this, ACDF reimbursements were assessed by combining the codes used in two of the most common procedures: ACDF utilizing an anterior plate and cage (2251, 22 845, 22 853) and ACDF utilizing an anterior plate and structural allograft (22 551, 22 845, 20 931). Reimbursement rates were tracked from 2016 to 2021 for all procedures except ACDF with cage. The CPT code for cage construct (22 853) was created in 2017, thus the reimbursement data for ACDF with cage spans 2017 to 2021.

Data Analysis

Yearly utilization data from 2011 through 2021 was collated and reviewed. Yearly reimbursement data from 2016 through 2021 was analyzed and the average annual reimbursement per procedure was calculated. Monetary value calculations were done with the U.S. Bureau of Labor Statistics’ 2021 Consumer Price Index by using the annual average for that respective year and converting it to buying power in June of 2024. Mean reimbursement per case for ACDF with cage, ACDF with allograft, and CDA were then found using this adjusted data. Procedural utilization and mean Medicare reimbursement per procedure was calculated and analyzed for the percent difference between the years 2016 and 2021. Descriptive statistics were used to analyze trends in procedure utilization rates and average reimbursement per procedure at a national level. A regression model was created to compare changes in reimbursement between both ACDF constructs and CDA.

Results

Utilization

2011-2021

From 2011 through 2021, a total of 403 589 single-level ACDF procedures were performed on Medicare Part B patients with a cumulative percent change of 24.0% and an average annual percent change of 2.5%. Throughout that same period, 8012 single-level CDA procedures were performed with a cumulative percent change of 1087.3% and an average annual percent change of 31.7%. Single-level CDA utilization increased at a significantly higher rate than that of single-level ACDF (P = 0.01).

From 2011 through 2021, a total of 340 529 multilevel ACDF procedures were performed on Medicare Part B patients with a cumulative percent change of 145.4% and an average annual percent change of 3.3%. The CPT code for multilevel CDA was created in 2015. From 2015 through 2021, 2516 multilevel CDA procedures were performed with a cumulative percent change of 453.0% and an average annual percent change of 37.0%. Multilevel CDA utilization increased at a significantly higher rate than that of multilevel ACDF (P = 0.02).

2016-2021

From 2016 through 2021, single-level ACDF procedures showed a cumulative percent change of −14.9% and an average annual percent change of −3.0%. Over the course of that same period, single-level CDA procedures increased by a cumulative percent change of 113.2% and an average annual percent change of 18.1%. Single-level CDA utilization increased at a significantly higher rate than that of single-level ACDF (P < 0.001).

From 2016 through 2021, multilevel ACDF procedures showed a cumulative percent change of −12.9% and an average annual percent change of −2.5%. During that same time, multilevel CDA procedures increased by a cumulative percent change of 259.1% and an average annual percent change of 33.6%. Multilevel CDA utilization increased at a significantly higher rate than that of multilevel ACDF (P = 0.04) (Table 1).

Table 1.

Annual Procedure Utilization

Procedure	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	% overall change	% Avg annual
SL ACDF	27 974	32 522	35 215	35 920	37 876	40 770	40 797	40 779	41 592	35 461	34 683	24	2.5
ML ACDF	22 362	26 360	29 067	29 588	31 938	34 381	35 051	35 324	36 042	30 459	29 957	145.4	3.3
SL CDA	118	99	147	248	391	657	968	1314	1392	1277	1401	1087.3	31.7
ML CDA					100	154	316	436	457	500	533	453	37

ACDF, anterior cervical discectomy and fusion; CDA, cervical disc arthroplasty; SL, single-level; ML, multi-level.

Reimbursement

2016-2021

From 2016 through 2021, Medicare reimbursement for single-level ACDF utilizing a cage increased from $3379 to $3547 with an average annual percent change of 1.19%. Reimbursement for single-level ACDF utilizing a structural allograft decreased from $3408 to $3206 with an average annual percent change of −1.25%. Over that same period, single-level CDA reimbursement increased from $1636 to $2779 with an average annual percent change of 9.96%. There was no significant absolute change or annual percent change between single-level ACDF with cage, single-level ACDF with allograft, or single-level CDA reimbursement. Medicare reimbursement for both single-level ACDF with cage and structural allograft were higher than single-level CDA in 2021.

From 2016 through 2021, Medicare reimbursement for two-level ACDF utilizing a cage increased from $4255 to $4406 with an average annual percent change of 0.86%. Reimbursement for two-level ACDF utilizing a structural allograft decreased from $3935 to $3160 with an average annual percent change of −4.8%. Medicare reimbursement for multilevel CDA increased from $2200 to $3289 with an average annual percent change of 7.42%. Medicare reimbursement for multilevel CDA was higher than multilevel ACDF with allograft, but lower than multilevel ACDF with cage (Table 2).

Table 2.

Annual Average Reimbursement per Procedure, Inflation Adjusted^a

Procedure	2016	2017	2018	2019	2020	2021
SL ACDF - cage		$3379.11	$3527.76	$3507.15	$3465.30	$3547.95
2L ACDF - cage		$4255.22	$4342.59	$4336.34	$4289.79	$4406.13
SL ACDF - allograft	$3408.80	$3391.93	$3288.06	$3320.68	$3350.64	$3206.59
2L ACDF - allograft	$3935.63	$3908.54	$3792.32	$3821.65	$3842.40	$3160.98
SL CDA	$1636.00	$1625.00	$2107.00	$2343.00	$2749.00	$2779.00
2L CDA	$2200.00	$2166.00	$2663.00	$2902.00	$3290.00	$3289.00

ACDF, anterior cervical discectomy and fusion; CDA, cervical disc arthroplasty; SL, single-level; 2L, two-level.

^aInflation adjusted based on yearly average buying power in June 2024.

In exploratory linear regression models of reimbursement over time, single-level and two-level CDA demonstrated significant annual increases in reimbursement (β ≈ +$266 and +$259 per year, respectively; both 95% CI intervals excluded zero), whereas ACDF constructs showed smaller, non-significant changes with confidence intervals crossing zero (Tables 3 –5).

Table 3.

Change in Reimbursement

Reimbursement Per Procedure^a
	SL ACDF - cage^b	SL CDA	P value	2L ACDF-cage^b	2L CDA	P value	SL ACDF-allograft	SL CDA	P value	2L ACDF-allograft	2L CDA	P value
2016	$3379	$1636		$4255	$2200		$3408	$1636		$3935	$2200
2021	$3547	$2779		$4406	$3289		$3206	$2779		$3160	$3289
Absolute change	$168	$1143	0.221	$151	$1089	0.28	$-202	$1143	0.104	-$775	$1089	0.18
Absolute percent change	4.97%	69.87%		3.55%	49.50%		−5.93%	69.87%		−19.70%	49.50%
Average annual percent change	1.19%	9.96%		0.86%	7.42%		−1.25%	9.96%		−4.8%	7.42%

ACDF, anterior cervical discectomy and fusion; CDA, cervical disc arthroplasty; SL, single-level; 2L, two-level.

^aInflation adjusted based on yearly average buying power in June 2024.

^bData in these columns begin in 2017, not 2016.

Table 4.

Itemized Reimbursement of CPT Code per ACDF Construct^a

Construct (with CPT Codes)	2016	2017	2018	2019	2020	2021
SL ACDF - cage
22551		$1757.00	$1770.00	$1836.00	$1899.00	$1925.00
22845		$744.63	$743.72	$750.82	$746.92	$729.15
22853		$266.49	$255.95	$267.09	$266.14	$260.27
Total before inflation		$2768.12	$2769.67	$2853.91	$2912.06	$2914.42
2L ACDF - cage
22551		$1757.00	$1770.00	$1836.00	$1899.00	$1925.00
22552		$403.06	$403.03	$407.66	$405.10	$395.36
22845		$744.63	$743.72	$750.82	$746.92	$729.15
22853 + 22853		$532.98	$511.90	$534.18	$532.28	$520.54
Total before inflation		$3437.67	$3428.65	$3528.66	$3583.30	$3570.05
SL ACDF - allograft
22551	$1745.00	$1757.00	$1770.00	$1836.00	$1899.00	$1925.00
22845	$742.46	$744.63	$743.72	$750.82	$746.92	$729.15
20931	$114.45	$114.76	$114.29	$115.35	$114.27	$111.47
Total before inflation	$2601.91	$2616.39	$2628.01	$2702.17	$2760.19	$2765.62
2L ACDF - allograft
22551	$1745.00	$1757.00	$1770.00	$1836.00	$1899.00	$1925.00
22552	$402.46	$403.06	$403.03	$407.66	$405.10	$395.36
22845	$742.46	$744.63	$743.72	$750.82	$746.92	$729.15
20931	$114.45	$114.76	$114.29	$115.35	$114.27	$111.47
Total before inflation	$3004.37	$3019.45	$3031.04	$3109.83	$3165.29	$3160.98

ACDF, anterior cervical discectomy and fusion; SL, single-level; 2L, two-level; CPT codes listed in Legend.

^aNot adjusted for inflation.

Table 5.

Regression Slopes and 95% CIs for Annual Change in Reimbursement

Procedure	Annual Change ($/yr)	95% CI Low	95% CI High
SL ACDF – Cage	27.5	−31.5	86.5
2L ACDF – Cage	24.9	−23.4	73.2
SL ACDF – Allograft	−31.5	−64.9	1.9
2L ACDF – Allograft	−115.5	−259.5	28.5
SL CDA	266.4	177	355.7
2L CDA	258.7	162.2	355.3

ACDF, anterior cervical discectomy and fusion; CDA, cervical disc arthroplasty; SL, single-level; 2L, two-level.

Discussion

When comparing procedure utilization rates, a modest increase of 24.0% was seen for ACDFs reimbursed by Medicare and a staggering increase of 1087% was seen for CDAs reimbursed by Medicare. In 2021, ACDFs were still performed at a significantly higher rate compared to CDAs for anterior based cervical spine decompression (34 683 vs 1401). Both procedures increased in utilization. However, only CDA showed a notable rise in reimbursement during the same period. While both utilization and reimbursement for CDA increased over the study period, this study does not establish a causal relationship between these trends, and any association should be interpreted descriptively.

A similar increase in CDA utilization was also identified in the general population. In 2010, CDAs accounted for 4.0% of cervical spine procedures compared to 14.1% in 2018 and 14.4% in 2021.⁴ A more drastic increase in CDA utilization was identified between the years 2006 and 2013, with CDA procedures increasing by 190% compared to only a 5.7% increase in ACDF procedures.⁵ While CDAs are commonly utilized in younger patients with preserved posterior column anatomy, this trend is still consistent within our study despite analyzing a typically older Medicare population. This may suggest a more generalizable increase in the popularity of cervical disc arthroplasty that is not directly linked to reimbursement rates.

Current events may also play a role in spinal surgical volume. A widespread decrease in spinal diagnosis and treated conditions is seen in the year following the COVID-19 pandemic,^6,7 This mirrors the decreased utilization of ACDF and CDA procedures revealed in our data in that same period.

While ACDF has shown an increase in utilization throughout the study period, reimbursement rates have, largely, plateaued. This plateau in reimbursement per procedure, despite an overall increase in procedure utilization, is mirrored by trends in other studies. Surgeon reimbursements for single-level and multilevel ACDF procedures decreased by 8.7% and 10.7%, respectively, when accounting for inflation between 2012 and 2017. Furthermore, hospital reimbursements saw a 1.5% inflation-adjusted decrease through this same time period.⁸ Interestingly, ambulatory surgery centers saw a 184.5% increase in ACDF procedures performed between 2015 and 2017.⁸ A review of the NSQIP database by Weiss et al⁹ between 2006 and 2016 showed an overall increase in the number of elective ACDFs being performed as outpatient procedures with an associated increase in readmission risk. These trends may indicate a mismatch in procedure risk and hospital reimbursement. This may also influence where surgery is performed. Unfortunately for high-risk patients, this could lead to preventable postoperative complications.

Cervical spine surgery utilization will likely continue to rise in the United States. ACDF utilization alone is expected to rise 13.3% (153 288 to 173 699) with the largest increases expected in the 45-54 (42 077 to 49 827) and 75-84 (8065 to 14 862) age groups between 2020-2040.¹⁰ This coincides with the aging population in the United States and the natural course of cervical spondylosis. As surgical utilization of ACDF and CDA procedures continues to rise, it is important to understand how trends in Medicare reimbursement may alter patient care and how this increase in demand may be accommodated. As reimbursement decreases, more ACDF procedures may shift to outpatient or ambulatory surgery centers. CDA procedure utilization will most likely follow this trend, given that these procedures are performed using the same approach and have similar risk profiles.

Although reimbursement is only one of the many factors that shape procedural selection, changes in payment models may gradually influence trends in ACDF and CDA use. As payment models continue to move toward value-based care, procedures that align with favorable long-term outcomes, lower readmission rates, or reduced overall costs may be more appealing to both surgeons and hospitals. The recent increase in CDA reimbursement may reflect growing recognition of its potential long-term advantages, but clinical decision-making for ACDF vs CDA remains driven mainly by patient anatomy, indications, and surgeon judgment.

Cervical fusion and arthroplasty have differing fees. According to the “Procedure Price Lookup for Outpatient Services” tool found on the Medicare website, the average facility fee for single-level ACDF in ambulatory surgical center is $8,864, while the average facility fee in a hospital setting is $12,539. Likewise, the facility fee for single-level CDA in an ambulatory center is $13,187, while in a hospital setting it is $17,756.

Research regarding the outcomes of these two procedures is numerous and ongoing. Both CDA and ACDF are considered safe and effective surgeries with good long-term outcomes.^11-14 In the acute postoperative period, CDA and ACDF procedures carry similar rates of in-hospital complications and survivability.¹⁵ Sasso et al showed no statistically significant difference between CDA and ACDF for neck disability index scores, the visual analog scale for neck pain, or the visual analog scale for arm pain.¹⁶

ACDF has been shown to achieve better cervical spine alignment.¹⁷ While arthrodesis of the cervical spine can be a powerful tool for deformity correction, it does come with the increased risk of adjacent segment disease. At 10 years, Nunley et al¹⁸ showed a 3.1% cumulative risk of adjacent level surgery for CDA vs a 25.5% risk in ACDF. In a more recent study, Zavras et al¹² demonstrated greater range of motion profiles and better patient reported outcomes with unconstrained and semi constrained CDA designs relative to ACDF. This is likely secondary to the mechanical design of cervical arthroplasty implants, which are less constraining than fusion, therefore allowing for retained range of motion. ACDF surgery was also associated with a longer mean hospital stay and an increased rate of reoperation when compared to CDA.^16,19 However, patients undergoing ACDF tend to be older and thus have an increased number of comorbidities when compared to a younger population of patients that more routinely have CDAs performed.^20,21 Additionally, in younger patients (45-65 years old), CDAs have been shown to have an overall lower societal cost.²² As CDA utilization increases more individuals may gain exposure to the procedure during training. This may facilitate a better understanding of indications and more comfort with surgical techniques.

Another factor in the increased adoption of cervical disc arthroplasty could be related to advancements in technology over the years. CDA received FDA approval in 2007 and improvements in implant design and surgical techniques have since followed. Refinements like patient-specific implants, robotics, and navigation systems have given physicians a wider variety of options when considering CDA as a treatment strategy.²³

Changes in payment models may also contribute to increasing CDA use. Previous RVU or fee-for-service care dictated payment based on the quantity of services provided, regardless of the quality of care. However, new value-based care models reimburse physicians and hospitals based on the quality and effectiveness of care provided. Policies such as these aim to reduce costs while improving outcomes and encouraging physician accountability.²⁴ Preliminary data suggests improved long-term outcomes of cervical arthroplasty and an overall reduction in cost, which could be driving the increase in Medicare reimbursement. Despite the rapid increase in CDA utilization, it does not compare to the gross utilization of ACDF surgeries performed annually within the Medicare population. It is unlikely that the number of CDAs performed will ever reach that of ACDFs, given the need for careful patient selection, socioeconomic factors, and implant cost.²¹ However, it is important to develop appropriate risk-adjusted payments as the reimbursement landscape continues to transition to value-based care and bundled payment models in order to maintain the quality of care and access for all patients.⁸ Otherwise, we may see patient care being negatively impacted by the financial decisions made by hospitals and privately owned surgery centers.

Limitations

This study has several limitations. First, the data was drawn exclusively from Medicare Part B claims. While this does capture a large division of the Medicare insurance market, it does not represent the entirety of the Medicare market. Another limitation of this study is the lack of patient-level data, which inhibits the ability to adjust for age, comorbidities, regional variation, and institutional factors. Additionally, this analysis does not include the broader privately insured market. The demographic differences between these two markets restrains the ability of this study to generalize the data. It should also be noted that the data within the National Medicare Summary relies on appropriate medical billing and coding. Potential miscoding, misclassification, or overlap between multilevel and single-level codes could alter the reported utilization, and changes in CPT code definitions over time (such as the introduction of 22 853) may contribute to variability in reporting. Variations in institutional billing practices or coding accuracy cannot be evaluated within this dataset.

Additionally, this review cannot account for the migration of ACDF and CDA procedures from inpatient hospitals to ambulatory surgery centers. Medicare Part B summary files compile physician services, but do not distinguish between inpatient and outpatient sites of care. As cervical spine procedures shift toward outpatient and ASC settings, observed changes in utilization may partially reflect changes in the site of service, rather than true underlying shifts in national procedural volume. This limitation also restricts the ability to evaluate how outpatient migration may influence coding practices, reimbursement patterns, or case selection. Finally, this study focuses on historical utilization and reimbursement patterns within Medicare and does not include forward projections. Incorporating forecasting models may provide additional policy insight and could be a helpful direction for future studies.

Despite these limitations, this study does provide valuable insight into the utilization of ACDF and CDA procedures in an aging population and how value-based payment models may be factoring into surgical decision making (Figure 1).

Figure 1.

(A) 6 Year reimbursement per procedure (single level). ACDF – Cage, anterior cervical discectomy and fusion utilizing a cage construct; ACDF – Allo, anterior cervical discectomy and fusion utilizing a structural allograft construct; CDA, cervical disc arthroplasty; (B) 6 year reimbursement per procedure (Two-Level). 2L ACDF – Cage, two level anterior cervical discectomy and fusion utilizing a cage construct; 2L ACDF – Allo, two level anterior cervical discectomy and fusion utilizing a structural allograft construct; 2L CDA, two level cervical disc arthroplasty

Conclusion

Both anterior cervical spine procedures saw increases in utilization over the study period, with cervical disc arthroplasty showing significant growth within the Medicare population. While the reimbursement rates for anterior cervical discectomy and fusion largely plateaued, the reimbursement rates for cervical disc arthroplasty demonstrated a considerable increase. It is important to understand these trends and how they fit into a newer value-based care model that emphasizes overall long-term cost reduction, so that we can better serve the aging patient population within Medicare.

Footnotes

ORCID iDs

John Clayton Davidson

Drew Melancon

Author contributions

J.C. Davidson: Contribution, data collection, manuscript writing/editing. Isaac Spears, Contribution: data collection, statistics, manuscript writing/editing; Brad Alexander: Contribution, manuscript writing; Drew Melancon: Contribution, data collection, manuscript editing; Rowdy Lee: Contribution, data collection; Martin McCandless: Contribution, data collection; Priyanka Nehete: Contribution, data collection; C. Julian Clark II: Contribution: data collection, tables/figures; Robert McGuire: Contributions, manuscript editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data is publicly available via the Center for Medicare Services National Summary Data Files.*

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