Neurosurgery Coding Alert

Busy physicians sometimes fail to indicate pertinent information in the medical record, including all relevant diagnoses or information describing a diagnosis(es) to the highest available level of specificity. Accurate diagnosis coding is as important as accurate CPT coding: A lack of precision often leads to decreased reimbursement and, more important, compromised quality of patient care.

While CPT codes tell "what" a physician does, ICD-9 codes explain "why" he or she does it, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. In other words, a patient's condition or diagnosis (represented by ICD-9 codes) dictates treatment options (represented by CPT Codes ). By the same token, based on section 1862(a)(1)(A) of the Social Security Act, if the ICD-9 Codes linked to a particular procedure or service cannot sufficiently explain why that procedure or service was reasonable and necessary, the claim will face rejection. To use an extreme example, no payer will reimburse for a diskectomy (e.g., 63077, Diskectomy, anterior, with decompression of spinal cord and/or root[s], including osteophytectomy; thoracic, single interspace) with a simple diagnosis of back pain (724.5) because such a diagnosis is insufficient to justify the procedure. A more precise diagnosis such as 721.41 (Thoracic spondylosis with myelopathy) is more likely to support the service.

Because diagnosis specificity describes the patient's injury or illness precisely, it is important in establishing medical necessity and further determines proper CPT coding. If a fourth or fifth digit is available to designate a diagnosis more exactly, the surgeon should code the highest available (and documented) level of specificity.

Use three-digit ICD-9 codes only when a fourth or fifth digit is not available: A code is invalid if it is not reported to the full number of digits required for that code, and claims with such codes attached will face rejection.

For example, according to ICD-9, the three-digit diagnosis code 722 describes "Intervertebral disc disorders." Without more information, this diagnosis provides the payer with only a general idea as to what treatment options are appropriate, and therefore the payer will reject any claim with such a diagnosis. Further specificity (and therefore more information to determine necessary procedures/services) can be indicated through use of additional digits. In this case, a fourth and fifth digit are used to specify the site or type of pathology (e.g., 722.0 describes displacement of cervical disk without myelopathy, 722.10 describes displacement of lumbar disk without myelopathy, 722.11 describes displacement of thoracic disk without myelopathy, etc.).

Even diagnoses coded to the fourth or fifth digit may be designated "unspecified." For instance, four-digit code 720.9 describes "Unspecified inflammatory spondylopathy," while five-digit code 722.30 describes "Schmorl's nodes, unspecified region." Generally, physicians should avoid these codes when possible. For example, a postoperative laminectomy (e.g., 63040, Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; cervical) to treat postlaminectomy syndrome is more likely to gain speedy reimbursement if a precise diagnosis (e.g., 722.81, Postlaminectomy syndrome, cervical region), rather than a less descriptive (e.g., 722.80, unspecified region) diagnosis, is attached.

In some cases, of course, an unspecified code is warranted because a more precise diagnosis is not known.

Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company, further notes that some payers (such as managed-care payers and fee-for-service Medicare payers) use ICD-9 codes to measure outcomes for physicians. Outcomes affect reimbursement, Fee Schedule negotiations, contract renewal and the future with a payer. If a doctor continues to use unspecified diagnoses, his or her data will be incomplete and the outcomes information will be skewed, which can hinder the physician's ability to negotiate future contracts and may result in removal from a good payer panel.