Neurosurgery Coding Alert

Every coder knows the frustration of dealing with multiple insurers, each with its own set of guidelines. Although Medicare policy and the national Correct Coding Initiative (CCI) provide a framework of generally recognized coding principles, documentation requirements, acceptable diagnoses to establish medical necessity for a given procedure or service, the preferred application and interpretation of modifiers, and other coverage issues still vary from payer to payer.

Those physician offices with Internet access can often find the coverage information they need quickly and efficiently on the Web. The trick is knowing where to look.

The Web site www.lmrp.net is a compendium of Medicare intermediary local medical review policies (LMRPs), updated monthly. The site allows searches by Medicare carrier, fiscal intermediary, etc., by CPT code or by using a combination of search terms, and also provides a page for the latest policy updates. By providing this information at a single, easy-to-access-and-search location, lmrp.net is the ideal source for coders looking for specific policy information.

For example, a coder working in a neurosurgery office in California must file a claim to Medicare for kypho-plasty. CPT contains no specific description of this procedure, so the coder must determine which code(s) the individual payer deems appropriate.

To find this information, log on to the lmrp.net Web site (www.lmrp.net) and choose the "search" function at the upper-right portion of the screen. The page that follows allows for several search options. First, you may choose the contractor by type (carrier, fiscal intermediary, DMERC, RHHI or all types). In this case, you are searching for the policy of your local carrier, National Heritage Insurance Company (NHIC). After you choose "carrier," a second window appears and asks you to select a carrier by region or name. Choose the carrier by name (NHIC) from the pull-down menu. Lastly, type the keyword or words (e.g., the specific CPT code or procedure name) that you want to search for. Enter "kyphoplasty" in the search field and click the "go!" button. In a few seconds, a link to NHIC's LMRP for kyphoplasty appears. Next to the heading "CPT/HCPCS Codes" the payer lists the code to report this procedure: 22899 (Unlisted procedure, spine).

If the coder had been in New York, however, he or she would have found that Empire Medicare, unlike NHIC, treats kyphoplasty as the equivalent of percutaneous vertebroplasty, recommending that the same CPT codes (22520-22522, depending on location) be used to report the procedure.

Using the same method, coders can find acceptable diagnoses (ICD-9 codes), coverage limitations (such as frequency and usage guidelines), instructions for applying modifiers (such as if modifiers -62 [Two surgeons] or -66 [Surgical team] are allowable) and even payment information.