General Surgery Coding Alert

When a disk is herniated, the spine is curved and can be fixed either from the back or front. Neurosurgeons and orthopedists tend to favor the anterior approach because it makes the spine more stable. But typically they will require the services of a general surgeon to move organs out of the way and to open and close.

But what is now a relatively straightforward surgical procedure has become a serious coding dilemma for both the orthopedic/neurosurgeon and the general surgeon. Kathleen Mueller, RN, CPC, CCS-P, a physician reimbursement specialist who works with Allan L. Liefer, MD, FACS, in Chester, Ill., says she has fielded more questions on this particular problem than any other in the past two years.

Orthopedic and neurosurgeons will use CPT Code 22558 (Lumbar arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace) for the procedure.

So far so good. The question is: how does the general surgeon code his or her role during the procedure?

Many surgeons, often at the request of the orthopedic or neurosurgeon, use CPT code 49010 (Exploration, retroperitoneal area with or without biopsy(s)), where the physician may obtain sample tissue for separately reportable diagnostic testing.

However, when the general surgeon codes the procedure 49010, the claim is likely to be denied and, worse, if a Medicare claim is filed with the Health Care Financing Administration (HCFA), the use of 49010 will be considered unbundling because the relative value units (RVUs) for orthopedic and neurosurgical procedures already include exposure of the spine.

HCFA: Unbundling is Fraud

According to regulations on unbundling found in its National Correct Coding Initiative, which went into effect in July 1996, HCFA banned the the use of laparotomy (i.e. 49000 and 49010) or thoracotomy (32100) codes for the purpose of exposing the spine and considers the use of these codes in such procedures fraudulent.

So, how should the general surgeon code his role in the procedure?

The short answer is simple: general surgeons are required to list the same code (22258) as the orthopedic or neurosurgeon, and both physicians should also add CPT modifier -62, which signifies that both were co-surgeons during the procedure.

Cynthia Thompson, CPC, a senior consultant with Gates Moore & Company in Atlanta, also points to guidelines from the American Academy of Professional Coders recommending that both surgeons coordinate the filing of their claims and send their documentation in together, because carriers vary widely in terms of what kind of documentation they require.

This may turn out to be tougher than it sounds. Mueller points out that even though adding the -62 modifier increases the reimbursement rate of the 22558 by 25 percent, the resulting fee must be split equally by the two physicians, which works out to less reimbursement than if the orthopedist or neurosurgeon filed the 22558 on his or her own.

If the ortho/neurosurgeon is unaware of the HCFA regulations on unbundling for this particular procedure, it may be difficult to persuade him or her that filing a 49010 would be not be in either physicians best interests.

Note: HCFA has said that filing 49010 in these circumstances may be considered fradulent billing since it is unbundled from 22558 and would constitute a $10,000 fine plus triple damages from both the general surgeon and the orthopedic or neurosurgeon, since both billed incorrectly. (If the ortho/neurosurgeon files the 22558 without the modifier -62, he or she will have received an overpayment, again, possible fraud.)

Once the orthopedic or neurosurgeon is on board, Thompson recommends checking with the carriers in question to find out what kind of documentation they require.

Even if the general surgeon leaves the OR after the opening and freeing of the vessels and returns only to close, he or she is still perceived to have been there for the integral part of the procedure and will therefore qualify as a co-surgeon.

Mueller adds that each physician must dictate their own operative report describing their part of the procedure and both need to be listed as either surgeon/surgeon or co-surgeon/co-surgeon, not surgeon and assistant.
The use of modifiers -80 or -82, which indicates a surgeon and an assistant, is not recommended in this instance, because HCFA may consider that to be fee-splitting.

Bone Harvesting Listed Separately

Mueller also points out that the instrumentation and harvesting of the graft should be listed in addition to the main procedure with no modifiers, and surgeons should be paid for such procedures because they are listed in the CPT book as list in additions to codes in the 22554 range.

If all the general surgeon does is open and close, all the get in on is the 22558; however, if they stay through the procedure and assist during the arthrodesis, he or she can bill add-on codes in this case, list in addition to codes, 20930-20938 (bone grafting codes) without using modifier -51, which would normally be used for multiple procedures. Because using modifier -51 cuts reimbursement in half, reading the operative report is critical because it enables you to find out what your surgeons did and then determine if an add-on code could be used instead of modifier -51.

If more than one interspace is involved in the 22558, 22585 (each additional interspace) should be attached, again with modifier -62.

Should the general surgeon remain throughout the entire procedure, it should be billed as modifier -62 on the 22558, and 20930-38 without a modifier for the instrumentation and harvesting of the graft.

In a final twist, Rita Scichilone, MHSA, CCS-P, a manager in the Coding Products and Services Division with the American Health Information Management Association (AHIMA), takes the position that the general surgeon should bill the original 49010 to commercial carriers, though not with HCFA.

Filing Co-Surgery With Commercial Carriers

You have to follow the HCFA guidelines for payment, she says, but you code for other reasons besides payments, such as data collection, decision support, and to realistically reflect actual services rendered.

Scichilone says that although HCFA clearly bans the use of the 49010 with a 22558, some commercial insurance companies may not, so general surgeons should submit it to other carriers, pointing out that spine surgery is performed mainly on young people, not Medicare recipients. She adds that physicians may code for reasons besides payment, such as data collection, decision support and to realistically reflect actual services rendered.

Mueller strongly disagrees. An office, she says, should have only one coding method, adding that if there is a coding policy in a physicians office, it should be HCFA policy, because the rules and regulations are spelled out in black and white.

Susan Stradley, CPC, of Moore Elliott in Augusta, Stradley concurs, pointing out that, increasingly, private payers are looking at HCFAs Correct Coding Initiative and retroactively going after payments, so even a previously successful 49010 claim today could be clawed back in the future.

Stradley, who was named Coder of the Year at the recent annual meeting of the American Academy of Professional Coders, also says the 22558-62 better describes the procedure than the 49010. The 49010 basically says we opened the chest and we closed it, Stradley says. The 22558-62 is much more descriptive. It says we opened the chest, we moved every organ out of the way, and then we closed the chest.

Finally, Mueller points to what is perhaps the most compelling reason for coding the procedure 22558-62 for commercial payers: the general surgeon will be reimbursed more.