Neurosurgery Coding Alert

Neurosurgery claims for spinal instrumentation (22840-22848) are being reduced and denied because of inappropriate actions by carriers and lack of coder knowledge. This confusion results from misunderstanding that spinal instrumentation codes are secondary and cannot be billed on their own.

Five Steps to Increase Pay Up Potential

1. Properly bill co-surgeries. A major problem arises when billing for the installation of instrumentation with co-surgeons. Sharon Tucker, CPC, president of Seminars Plus, a medical coding and billing consulting company based in Fountain Valley, Calif., explains that, In the operating room, one doctor may perform the primary procedure and fusion while the other handles the instrumentation. Under these circumstances, they both must work together when billing. If the primary surgeon bills separately for the arthrodesis (22612), while the second bills for the instrumentation (22842), the second physicians claim will likely be denied, because instrumentation codes cannot be billed on their own. They are only reimbursed when they are billed together with a primary procedure.

Tucker suggests both physicians bill as co-surgeons for the primary procedure using modifier -62 (two surgeons). The doctor who is responsible for installing the instrumentation would bill that code without a modifier as well. Both should write detailed, complete operative notes that document distinct roles. Alternately, the physician who performs the instrumentation could bill as an assistant for the primary procedure using the -80 modifier (assistant surgeon), plus the code for the instrumentation.

Coders should work closely with their neurosurgeon and the other physicians staff to develop a coding plan that reflects both contributions to ensure appropriate reimbursement for all parties.

2. Understand carrier criteria for choosing spinal instrumentation codes for vertebral segments and vertebral interspaces.

These rules of thumb below will prevent carriers from down coding or delaying your payments due to confusion over how many levels of spinal instrumentation were inserted into the patient.

Codes for segmental instrumentation are based on the number of segments spanned. For instance, 22842 covers three to six segments, while 22843 covers seven to 12, and 22844 covers 13 or more.

Instrumentation is never coded alone, so the use of modifier -51 (multiple procedures) is not necessary.

Occasionally, a metal cage or other prosthetic device is placed for stabilization in an area where a large portion of the vertebra has been removed. It is usually filled with an acrylic resin called methyl methacrylate. When more than one cage is placed in the same intervertebral space at the same level, use 22851 (application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace) just once. When cages are placed at more than one level, indicate by number of units on the HCFA 1500 form how many levels were treated.

The coder must be careful to count vertebral segments and interspaces carefully to ensure that the right spinal instrumentation code is chosen so the correct number of levels are reimbursed. For instance with T11-L3, there are five vertebral segments and four interspaces (T11- T12, T12-L1, L1-L2, and L2-L3).

List the different sites where spinal instrumentation is placed in the documentation to provide back-up for the claim.

Additional levels of spinal instrumentation should not be entered separately on the claim; this could cause denials for duplicate services. When entering additional levels, add up the number and indicate the quantity in the units field on the HCFA 1500 form.

Do not bill separately for spinal instrumentation placed on the left and right side of the spine. Instrumentation is inherently bilateral and is billed based on the number of levels.

3. Documentation for new carriers. If you are dealing with a new carrier it will save you time in the payment process to include documentation with your initial claim, suggests Brenda Bosch, CPC, reimburse-ment analyst for St. Alexius Medical Center in Bismark, N.D., and a 22-year coding veteran. Weve had to send in full operative reports to prove that an entire disk was removed to get into the space, and that a decompression of the spinal cord was performed, says Bosch, a former American Academy of Professional Coders chapter president. She also recommends including a letter explaining the medical necessity for the primary procedure and the spinal instrumentation. Medical necessity needs to be thoroughly documented and backed up with appropriate ICD-9 codes such as 722.52 (degeneration of lumbar or lumbosacral intervertebral disc) or 724.02 (spinal stenosis of lumbar region). It should be made clear when you submit your claim that these procedures were done to address significant and distinct problems.

4. Modifiers for removal. When coding for spinal instrumentation that has to be removed because the spine fails to fuse, the patients body rejects it, or adjustment is needed, then certain modifiers should be applied.

When the surgery is performed during the 90-day global surgical period, the appropriate modifier should be added to the primary procedure and instrumentation code;

If the instrumentation is removed at the time of the original procedure, then modifier -58 (staged or related procedure or service by the same physician during the postoperative period) can be used;

Should the neurosurgeon return the patient to the operating room because his or her body is rejecting the instrumentation, then modifier -78 (return to the operating room for a related procedure during the postoperative period) is appropriate;

If the patient returns to the OR, for example, because surgery needs to be performed on a different part of the spine, then use modifier -79 (unrelated procedure or service by the same physician during the postoperative period).

5. Carrier education. Some third-party payers attempt to reduce reimbursement for spinal instrumentation on the grounds that codes for fusion (22548-22812) and instrumentation are adjunct codes. For example, a neurosurgeon does not do instrumentation without fusion.

But CPT 2001 lists 22840-22848 and 22841 as modifier -51 exempt. Therefore, they are not subject to reduction, because their RVUs were calculated to reflect that they are always done in addition to a primary procedure, explains Anita Daye Foster, MA, CPC, of The Coding Network, a group that provides coding services to academic environments in Beverly Hills, Calif. To reverse these payment reductions, coders should follow these simple tips:

Communicate with the carrier by phone, fax, or possibly a personal visit to show them that the reductions are wrong according to HCFA RVU data;

Get any agreements with the carrier in writing; and

Monitor claim explanation of benefits (EOBs) to make sure the carrier does not continue the reductions.