Neurosurgery Coding Alert

The ambulatory payment classification (APC) regulations set forth by the Health Care Financing Administration (HCFA) will soon take the thousands of codes that are used for outpatient services and consolidate them into a smaller group of 451 APCs. This new programs effective date has changed from July 1 to Aug. 1.

These new codes will take into consideration every aspect of outpatient care, including usage of medical supplies, staffing efficiencies, and several other operational costs. Further, coders will be required to use them in outpatient clinics, emergency departments, diagnostic radiology, respiratory therapy, and ambulatory surgery centers. According to HCFA estimates, these codes will result in a potential 4.6 percent average increase in Medicare payments for hospitals and outpatient facilities.

How Reimbursement Is Affected

The APCs will not directly impact the way neurosurgeons and other Part B providers code and bill for services for Medicare patients. This is true even if the hospital is doing the neurosurgeons billing. There are ways, however in which the neurosurgeon may be affected.

Jack Turner, MD, PhD, medical director for documentation, coding and compliance with Team Health, a physician staffing company in Knoxville, Tenn., says that if hospitals and outpatient facilities begin to lose money on certain procedures, they no longer may make them available and that will affect the neurosurgeons potential earnings and ability to provide the best possible care to his or her patients.

What we have to recognize is that what we write on a chart, what medications and tests we order, and what procedures we perform will now greatly influence the bottom line of the hospital, Turner says. We have to be concerned about how the hospital will fare with this new system of reimbursement. The physician who is performing outpatient procedures needs to consider the well-being of the hospital as well as the well-being of the patient. If the hospital doesnt get paid, theyre going to suffer, and ultimately, that affects where we are going to perform our procedures and what procedures we may perform.

Catherine A. Brink, CMM, CPC, president of Healthcare Resources Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., that consults with several neurological practices, reports that neurosurgeons writing chart documentation for outpatient procedures such as electromyograms (EMGs, 95860-95872), nerve conduction studies (95900-95904), epidural blocks (62310-62319, 64479-64484), and any other procedures performed on Medicare patients at hospitals or outpatient facilities will have to be extremely accurate and extensive for hospital and outpatient facility coders to bill properly.

For example, a common neurosurgical outpatient procedure is carpal tunnel release (29848). If the neurosurgeon simply indicates carpal tunnel release on his or her chart notes, the hospital coder may erroneously bill this as 64721 (neuroplasty and/or transposition; median nerve at carpal tunnel), and the bill will be placed under APC 220, which pays $676.88. The correct code, however, 29848, is part of APC 041, which pays $1191.33. The neurosurgeon who does not clearly indicate the exact service performed may, in this case, cause a loss in reimbursement of $514.45.

Documentation Is a Critical Key

According to Brink, the APCs will require hospitals and outpatient facilities to code and bill in an entirely new way. In essence, when a neurosurgeon performs a procedure in a hospital or outpatient facility for a Medicare patient, he or she will continue to bill for the professional component of that procedure with the Medicare Part B HCFA 1500 form, exactly as before.

Under the APCs, however, all of the hospital or outpatient facilitys bills for the technical component of the procedure have to be consolidated into one. This means the bill cannot be submitted for reimbursement until every department submits their portion of the entire bill to central billing, and that bill is itemized and correctly coded. All applicable nursing services, x-rays, medications and treatments performed by hospital staff (such as injections), along with charges for the room, equipment, disposable items, etc., are listed all at once on the Medicare Part A UB92 form.

Further, the hospital or outpatient facility coder will have only one opportunity to submit a bill; Medicare will not accept late or ancillary billing. Now, more than ever, the hospital needs the help of the neurosurgeon with precise and comprehensive chart note documentation.

According to a June 2000 report to Congress by the Medicare Payment Advisory Commission (MedPAC), The new payment system gives hospitals an incentive they previously lacked to code visits accurately. This is because codes that seem similar in scope may belong to different APCs.

Proving Medical Necessity is Key

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, recommends that neurosurgeons and coders pay more attention to diagnosis coding, which will be even more important to document the medical necessity for a procedure. Also, what will prove to be most important for billing is the coordination between the neurosurgeon and the hospital. The responsibility for the billing and the coding will fall on the hospital.

But, as Brink is quick to remind neurosurgeons, documentation will have to be extremely accurate and extensive for the hospital coders to be able to bill properly. The neurosurgeons documentation is going to have to back up the intensity and the medical necessity for the codes charged. If the documentation is lacking, the neurosurgeon will have a problem proving the need for the procedure.

Dealing With Hospital and Emergency Departments

Sandham reports that neurosurgeons who do consultations in emergency room settings are going to be dealing with patients who receive a great deal of ancillary services, and the neurosurgeon will need to be attuned to whatever final interpretations of these guidelines Medicare establishes. The intensities of the services that neurosurgeons provide in an outpatient basis will be reflected in how the hospital ultimately can describe that service.

Hospitals will respond to this new program by developing more efficient outpatient treatment and coordinating better with their neurosurgeons on patient encounters because it is going to be required that hospitals compare what the procedures cost and what they can bill with the APCs. Hospitals will be looking to find ways to do procedures cheaper and to save money on the basic care. Outpatient service providers will need to find ways to use personnel more efficiently as well.