Neurosurgery Coding Alert

Neurosurgeons often treat patients who are filing or intend to file workers compensation claims for injuries suffered on the job. But getting paid for these services often is challenging. By monitoring payment amounts and researching carriers, neurosurgeons can ensure they are properly reimbursed by workers comp plans.

Anita Daye Foster, MA, CPC, CCS-P, senior vice president of Coding and Operations for The Coding Network in Hawthorne, Calif., an independent coding consultant to a variety of organizations and academic facilities including USC, UCLA, Stanford, and Yale, cautions that some workers comp carriers do not always follow their own rules or pay at appropriate rates according to their own manuals.

If you use microscopic dissection (69990), an adjunct code specific to certain procedure codes, many workers comp carriers will reduce it by 50 percent, and if you do laminectomies (63045) at multiple levels (63048), they will reduce the multiple level code, Foster says. But this is inappropriate. Adjunct codes carry a unit value that takes into consideration that they do not warrant a modifier -51 (multiple procedures). They are already reduced. Such improper practices by workers comp carriers must be monitored and challenged by appeal.

Foster suggests that if neurosurgeons deal with a high volume of workers comp cases, they should upgrade their billing software by programming in the relative value units (RVU) as established by the workers comp carriers in their states. Many offices have coders sending out bills and claims processors receiving payments. By upgrading the software to calculate the appropriate amount that should be paid at the beginning of the billing process, any inappropriate reductions can be caught easily. Staff productivity also will be improved because claims processors will not have to manually look up and calculate the amount that should have been paid on each claim. That information will be apparent immediately with a quick comparison of what should have been paid with the amount received.

Research Which Codes Carriers Are Accepting

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, says that Medicare always uses the most up-to-date codes, but workers comp carriers are not required to do so. Some workers comp carriers in New Jersey use CPT 1994, for example, while others in Florida use CPT 1996, and still others in California use CPT 1999.

Foster says getting current codes paid by certain workers comp carriers can be difficult. And when they are paid, it may not be at the appropriate amount because there are no set RVUs for these codes in that particular workers comp fee schedule. Copies of the appropriate pages from the current CPT and RBRVS regarding these codes may be sent during an appeal if a lower-than-appropriate fee is remitted, or they may be submitted up front with the claim.

Foster says that some workers comp carriers may ask a neurosurgeon to use an unlisted code for some procedures. In this case, documentation such as an operative report describing the procedure in detail should be submitted. Another alternativeone that should be used only if a request from the individual workers comp carrier is made in writingis to use the closest representative code if the compensation is also comparable.

Some individual workers comp carriers may own copies of the current CPT and RVU, even though the state department through which they contract is still using older information. For example, Laura Vorhes, CPC, coding and reimbursement specialist for Neurosurgical Associates, an eight-member neurosurgery practice in Minneapolis, says that in Minnesota, the state department that runs workers comp still uses CPT 1994. The neurosurgeons for whom she bills, however, still get paid for procedures that are not listed in their states specific fee schedule. Vorhes says, In neurosurgery, bone graft codes (20930-20938) are not in our Minnesota fee schedule because they have been developed since the publication of the 1994 CPT. Her office does not have difficulty getting paid for those, however, because the individual payers she works with have up-to-date information available.

Vorhes says that the workers comp carriers to whom she submits claims require documentation on every patient for every claim. We are also required to notify the workers comp insurer ahead of time to get approval for surgery, MRI scans and complex procedures.

Crossing State Lines

Tamara Middleton, CCS-P, analyst supervisor for the centralized abstracting unit at the University of California at Davis in Sacramento, says that because workers comp varies so greatly from state to state, businesses with satellite offices throughout the country must be particularly careful when their workers comp claims are handled from their home office. In California, we may be treating patients from Oregon, Washington, Nevada, etc., Middleton says. In such a scenario, the carrier is going to pay by their state guidelines, not those in which the injury occurred.

Middleton says that education is extremely important with workers comp, and she urges coders to attend seminars put on by the various state agencies in a neurosurgeons local area. You can also network with other people who are coding in your area and may have found solutions to workers comp dilemmas that you have only begun to face.