Neurosurgery Coding Alert

Alert your surgeon: Insufficient physician documentation causes serious reimbursement shortcomings, according to the most recent Comprehensive Error Rate Testing (CERT) results.

The report, released May 16, revealed that missing or incomplete documentation, including lack of documented medical necessity, accounted for over half of all Medicare payment errors between Oct. 1, 2006, and Sept. 30, 2007. In the same period, Medicare requested the return of $9.3 billion in reimbursement -- out of an improper-payment tally of $10.2 billion.

Although improper payments, as a percentage of total payments, have fallen in the past decade, "an error rate of over $10 billion is still high," notes Jay Neal, a consultant in Atlanta.

A shocking statistic: Neurosurgery claims account for over 15 percent of all payment errors CERT uncovered -- which makes neurosurgery the third most error-prone specialty (after occupational therapy and infectious disease) among over 40 specialties the report surveyed.

"Of the specialties I-ve worked with, neurosurgery ranks high on the difficulty scale," comments Denae M. Merrill, CPC-E/M, of Merrill Medical Management. She suggests that one reason for the high error rate in neurosurgery is the number of codes typically involved in a single procedure.

"A -simple- laminectomy with fusion, for example, has an average of seven codes," Merrill notes. "There is also the issue of bundling, from a CPT and/or Correct Coding Initiative [CCI] perspective, which then needs modifier consideration."

Action point: Go through your op notes line by line to determine every procedure the surgeon performs. When you have assigned a code for each separate portion of the surgery, check to be sure that there are not any bundling issues that would prevent you from billing all the codes. You should also check if modifiers may be necessary to report some components separately.

Another potential problem, Merrill comments, is the detail inherent in neurosurgery code descriptors. "They can appear similar at quick glance. But, upon reading more carefully, you may find one different word, and that changes the definition completely."

What to do: Read code descriptors fully and carefully. "Having a good understanding of anatomy and related medical terminology is important," Merrill continues.

Consults remain a trouble area: The CERT report also reveals that E/M coding, and particularly coding for all types of consults, remains a problem for all physicians, regardless of specialty. Past investigations by the Office of Inspector General and others have concluded that insufficient documentation of the consult request, reason and report are generally to blame for incorrectly-filed consultation claims.

Help is on the way: Watch Neurosurgery Coding Alert in coming months for a full explanation of how to report consultations successfully.

See for yourself: To read the full CERT results, visit the CMS Web site at http://www.cms.hhs.gov/CERT.