Anesthesia Coding Alert

4 critical ways to combat carrier challenges

Every coder has experienced the frustration of trying to accurately report services that don't have a specific code. This problem comes up a lot in pain management, where appropriate code choices seem to be years behind procedure techniques.

But unlisted-procedure codes don't have to mean automatic denials or write-offs. Read on for tips on how to hone your reporting strategies and boost your bottom line.

Common Procedures = Common Problem

CPT lacks specific codes for many common pain management procedures, including: 
 

Spinal hardware injections
 

IV sympathetic nerve blocks
 

Ganglion impar injections
 

Pulsed radiofrequency of any nerve
 

Destruction of dorsal root ganglion, lumbar sympathetic nerves, SI (sacroiliac) joint nerves.

When you don't have a specific code, you typically report 64999 (Unlisted procedure, nervous system). But you have other options. Other codes with potential pain management use include 22899 (Unlisted procedure, spine) and 27299 (Unlisted procedure, pelvis or hip joint), says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver.

Note: One procedure that recently dropped off the unlisted-procedure-code list is intradiskal electrothermal therapy (IDET). CPT Codes introduced a Category III code for IDET effective July 1, 2004 (0027T, Endoscopic lysis of epidural adhesions with direct visualization using mechanical means [e.g., spinal endoscopic catheter system] or solution injection [normal saline] including radiologic localization and epidurography). Once CPT includes a Category III code, you must report it for the procedure (instead of an unlisted-procedure code) unless a carrier specifically states it is incapable of processing Category III codes.

'Close' Doesn't Count in Coding

Many coders try to avoid reporting "unlisted-procedure" codes such as 64999 because they don't adequately describe the procedure in question. Because of this, some coders reported codes that were close to the procedure performed instead of the appropriate section's unlisted-procedure code. That's not a good habit to acquire, for a number of reasons.

Fraud alert: The primary reason this is inappropriate is because of potential fraud. "Selecting a code that is 'close' is not compliant coding," Hammer says. "Knowingly and willingly coding a service or procedure with a code for the explicit motivation of bypassing denials and ensuring payment is fraud. The documentation will not support the procedure being billed."

"It's never appropriate to choose a code that is close but doesn't really fit the procedure," agrees Gina Graham, CPC, an anesthesia and pain management coder in Hepzibah, Ga. "One way that the American Medical Association (AMA) tracks the need for new codes is through the unlisted procedures that are reported. At some point they may create a Category III code for further tracking. If the coder continually picks codes that are close to the real procedure instead of using the unlisted code, she is being non-compliant and is being improperly reimbursed. She also is impeding the natural progression of code development for the CPT manual."

Checkpoint: In some instances, Graham adds, it might be appropriate to add modifier -22 (Unusual procedural services) to indicate increased difficulty during the procedure (such as when the physician administers transforaminal injections through a different route into the spine). Coders may opt for this (or add modifier -52, Reduced services, instead when the practitioner performs a portion of a procedure) in geographical regions such as New York where carriers do not reimburse for "unlisted-procedure" codes. Some coders recommend this approach if the carrier denies your claim with 64999 and also denies your follow-up appeal.

In addition to these non-compliance viewpoints, CPT includes instructions that you should not select a CPT code that merely approximates the service provided. If no such procedure or service exists, CPT directs you to report the service using the appropriate unlisted-procedure or -service code. The implication is that it's no longer acceptable to choose a code that is "close" to what was performed, Hammer says.

Prepare to Address Roadblocks

Many of the challenges associated with reporting 64999 for so many pain management procedures fall into two categories: CPT-related and carrier-related.

"CPT bases unlisted-procedure codes on anatomic site in most instances, so one code for the nervous system is somewhat problematic," Hammer says.

Graham agrees. "The neurological system is such a complex one that you could only hope the AMA would create an unlisted code for procedures for the brain, the spine, and the peripheral nervous system," she says. "Other CPT chapters include numerous unlisted codes. Having only one unlisted code for the entire neurological section is not adequate for coding all unlisted pain management procedures."

Carrier challenge: Once your claim reaches the carrier, Hammer says, some don't understand the need for reading and understanding the information you submit. Another challenge is finding carrier representatives who educate themselves about new (and proven) technology or procedure techniques and therefore understand your claim.

How do you meet these challenges? Education and documentation are your best bets.
 

Track new procedure preferences. When a provider starts performing a "new" procedure, Hammer recommends that you verify with top payers from your provider mix whether they cover the procedure. If so, learn how each carrier wants you to report the service - with a HCPCS code, a Category III code, or an unlisted- procedure code. Create a spreadsheet of the preferences for your coders to use for correct billing.

Cover the bases with your cover letter. An information-packed cover letter with your claim plays an important role in reimbursement:

1. Write a brief paragraph explaining why you are using the unlisted-procedure code. Hammer typically includes the quotation about unlisted-procedure codes directly from AMA CPT instructions (see the Unlisted Service or Procedure notes in guidelines for each CPT section).

2. Include a brief paragraph explaining the procedure performed and why it is medically necessary for this patient. Also summarize other pain management procedures the patient has undergone without successful pain relief.

3. Include a brief paragraph explaining the basis for the fee submitted for the unlisted procedure. Common denominators include similar work, practice expense and malpractice risk to a "valid" CPT code. Basing your fee on a similar procedure is helpful but not mandatory.

Report related services correctly. All unlisted- procedure codes are "stand alones," meaning you cannot append modifiers to them. Instead, take appropriate modifiers into consideration when you calculate the fee. Begin by basing your fee on a comparable procedure and adjust it according to how any modifiers might affect it (such as reducing the fee if you would normally append modifier -52 to the claim). However, you can report 64999 in conjunction with other services performed at the same session that do have valid CPT codes (such as 20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s], or 20553, ... single or multiple trigger point[s], three or more muscles, for trigger point injections during the same visit).

Lobby for new codes. The AMA encourages providers to suggest new codes for inclusion in CPT. It's a long, drawn-out process, but some pain management providers believe it's worth pursuing.