Here are five tips for billing and coding for spine procedures at surgery centers from National Medical Billing Service’s Senior Vice President, Coding Jessica Edumiston
1. Obtain correct physician documentation
Obtain full documentation for spine procedures, operative notes, anesthesia and medication list before you begin coding.
“You have to make sure all is in order before starting to code,” says Ms. Talton. “There are several challenges, especially when we have more than one procedure. We have to ensure we are assigning the level of specificity for any spine procedure and the correct modifiers. Claims can be denied because modifiers are not affixed to the second tertiary procedure. That can be very costly and time consuming from a revenue cycle point of view.”
This documentation will become even more specific after the transition to ICD-10 in October 2014. Surgery centers can provide physician education courses to make sure they are ready for the transition.
“Physician education is going to be critical during the upcoming days, weeks and months leading up to ICD-10 conversion,” says Ms. Talton. “Physicians need to be made very aware of how they are noting procedures. They need to be very specific and aware of how they are wording their reports to avoid ambiguity in their operative findings. I suspect there will be physician queries when the operative notes are not clear, so if there is an opportunity for physician education, start now and continue through implementation. Otherwise, there is a huge drop in reimbursement because of that.
2. Code for add-ons when possible, but don’t unbundle
Coders often miss opportunities to include add-on codes, especially with spine surgery. When procedures are performed on one level followed by a subsequent procedure, you can use an add-on code.
“The correct way to code multiple procedures is to code the first procedure and use an add-on for the second,” says Ms. Talton. “However, they must be careful not to unbundle or bundle CPT codes because that’s an unethical procedure.”
Avoid unbundling if there are incidental services in the surgical package reported, which are included within the main procedure. “They should check each procedure code with CPT bundling edits and pay attention to CPT guidelines when they are coding,” says Ms. Talton. “Query the physician to make sure the second procedure wasn’t included in the main procedure.”
3. Employing modifiers
There are a few spine cases that can be billed with modifiers. Coders must know when to use modifiers appropriately.
“If the second procedure was done in a separate area with a separate incision, then it could be separately billable,” says Ms. Talton. “Otherwise, it’s part of the main procedure. I would encourage coders to check the operative notes and procedure book carefully before using additional codes and modifiers. The most common coding error is the overuse of modifier -59, which is inappropriate in some situations.”
4. Understand the coded anatomy
Coders should understand the anatomy of the spine before coding those procedures, especially as the codes become more specific after the ICD-10 transition. Carefully double check operative notes and documentation before beginning the claim.
“Make sure that the description of the report matches the procedure performed,” says Ms. Talton. “Moreover, with ICD-10, it’s going to be specific as it relates to anatomy. Coders need to be careful when assigning codes and make sure they understand what procedure the physician performed.”
Inconsistencies in the operative reports and procedure described by the physician cause delays and an inappropriately coded claim will lead to denials.
5. Continue coder education as procedures evolve
Spine surgeries have increasingly transitioned from inpatient procedures to minimally invasive outpatient surgeries. More will be performed in the surgery center setting in the future, as quality and cost-effective data are made available, and coders need to stay educated on new techniques.
“Having the procedure done in an ASC has higher quality than the hospital setting and with reduced cost and overhead,” says Ms. Talton. “This saves the insurance company thousands per patient per procedure.”
Some are adding 23-hour post-surgical facilities to perform more complex procedures. New minimally invasive procedures allow patients to recover more quickly, and the surgery center is able to offer a more favorable nurse-to-patient ratio than the hospital for higher patient satisfaction.
“As technology advances and more physicians and surgeons are educated on technology, I see that performing spine cases will become more of a standard case in ASCs in the future than it is now,” says Ms. Talton. “It’s up and coming now, and I see it taking off rapidly in the future.”
Ref. Becker’s Healthcare
This post was first published January 23, 2013 and was updated July 29, 2020.