Neurosurgery Coding Alert

Know beforehand which codes might not get paid.

Hindsight is always 20-20 when it comes to denials. Some denials are easily preventable if you had just taken the appropriate measures to prevent them beforehand. When it comes to diagnosis and procedural code compatibility, you should be aware of the steps you can take to reduce the likelihood that a procedure will be denied based on its assigned diagnosis code.

One of the most underutilized features found in any specialty coding book is the CPT®-ICD-10 crosswalk option. With it, you can find out which diagnosis codes will probably be paid when billed out with a particular procedure code.

Read on for more tips, tricks, and advice on how to implement the coding crosswalk feature into your arsenal of coding abilities.

Check Procedure Code Crosswalk for Relevant Dx

When it comes to neurosurgery coding, there are numerous procedure and diagnosis code combinations that you can assume match up together merely based on their anatomical relevancy to one another.

For example: Code 63075 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) can be an effective treatment for disc herniations. Therefore, it would make sense that this procedure's ICD-10 crosswalk will include a diagnosis code for disc herniation of the cervical spine. Using the coding crosswalk feature, you will find that M50.2- (Other cervical disc displacement...) does match up with 63075, which means that there should be no payment hold-ups due to an incompatible diagnosis code.

Caveat: The keyword here is "should." While you can rely on coding crosswalks as a guide, it's ultimately up to the payer's discretion whether or not to pay for a code.

"Although a particular code's crosswalk determination offers general guidelines, you never know if a private payer could deny a claim," states Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, Vice President at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. "It does, however, indicate that you could appeal and win based on medical necessity."

The same idea applies for procedures that do not correspond to a particular diagnosis in the code's crosswalk. Specific surgeries, for instance, still have a likelihood of being paid even if you cannot find the diagnosis code under the procedure code's crosswalk.

The end goal here is to reduce any and all unnecessary denials due to incompatible diagnosis codes. The idea of utilizing the crosswalk feature might sound tedious at first, but it could end up paying dividends by helping to streamline the administrative process.

Hindsight is always 20-20 when it comes to denials. Some denials are easily preventable if you had just taken the appropriate measures to prevent them beforehand. When it comes to diagnosis and procedural code compatibility, you should be aware of the steps you can take to reduce the likelihood that a procedure will be denied based on its assigned diagnosis code.

One of the most underutilized features found in any specialty coding book is the CPT^®-ICD-10 crosswalk option. With it, you can find out which diagnosis codes will probably be paid when billed out with a particular procedure code.

Read on for more tips, tricks, and advice on how to implement the coding crosswalk feature into your arsenal of coding abilities.

Check Procedure Code Crosswalk for Relevant Dx

When it comes to neurosurgery coding, there are numerous procedure and diagnosis code combinations that you can assume match up together merely based on their anatomical relevancy to one another.

For example: Code 63075 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) can be an effective treatment for disc herniations. Therefore, it would make sense that this procedure's ICD-10 crosswalk will include a diagnosis code for disc herniation of the cervical spine. Using the coding crosswalk feature, you will find that M50.2- (Other cervical disc displacement...) does match up with 63075, which means that there should be no payment hold-ups due to an incompatible diagnosis code.

Caveat: The keyword here is "should." While you can rely on coding crosswalks as a guide, it's ultimately up to the payer's discretion whether or not to pay for a code.

"Although a particular code's crosswalk determination offers general guidelines, you never know if a private payer could deny a claim," states Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, Vice President at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. "It does, however, indicate that you could appeal and win based on medical necessity."

The same idea applies for procedures that do not correspond to a particular diagnosis in the code's crosswalk. Specific surgeries, for instance, still have a likelihood of being paid even if you cannot find the diagnosis code under the procedure code's crosswalk.

The end goal here is to reduce any and all unnecessary denials due to incompatible diagnosis codes. The idea of utilizing the crosswalk feature might sound tedious at first, but it could end up paying dividends by helping to streamline the administrative process.

Check Before Billing Out with M46.-

Sometimes, there's no rhyme or reason as to why a particular set of diagnosis codes don't align with a given procedure. While a physician might perform a laminectomy to treat a diagnosis of spinal stenosis, often the stenosis is a result of another underlying condition, such as facet arthropathy. However, as you will see, the most appropriate diagnosis code is not always going to match up with a given surgical procedure.

For example: You're probably well aware that both M43.06 (Spondylolysis, lumbar region) and M48.06 (Spinal stenosis, lumbar region) correspond with code 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis], single vertebral segment; lumbar) in the coding crosswalk. However, when you look for M46.96 (Unspecified inflammatory spondylopathy, lumbar region) under 63047's crosswalk, you will come away empty-handed.

One of the first rules you learn as a certified coder is to code the underlying disease, not a symptom of the underlying disease. So, in the scenario where facet arthropathy results in spinal stenosis, you will want to be aware that an application of the facet arthropathy code M46.96 very well may lead to a denial, despite the fact that it is the most accurate code available.

Code both: If you wind up in the situation above, it's perfectly acceptable to code M46.96 as the primary diagnosis and M48.06 as the secondary diagnosis. However, the general rule is not to include any secondary diagnoses that exist as a result of the primary diagnosis. If the provider does not specify that one diagnosis is a result of the other, you may apply both codes.

Another example: Consider the lumbar spinal fusion procedure 22633 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace [other than for decompression], single interspace and segment; lumbar). Occasionally, a surgeon will perform this procedure on a patient to alleviate spondylolisthesis. However, if you cross-reference this code in the ICD-10 crosswalk, you will not find code M43.16 (Spondylolisthesis, lumbar region) as an applicable diagnosis code.

Look Out for E/M Crosswalks

If you cross-reference an E/M code in your coding crosswalk, you will find the same set of applicable diagnosis codes for each E/M code. The rules for cross-referencing diagnosis codes with surgical procedural codes are not the same when it comes to E/M visits, however.

"E/M services are paid as long as there is a medically necessary reason for evaluation and management," Cobuzzi says. "Most diagnoses (within reason) will support a standard E/M visit. However, it's important to keep in mind that not all diagnoses will support a higher-level E/M code."

Still, a payer may deny an E/M service for a diagnosis code that indicates the patient's underlying presenting problem. "Determining what diagnosis codes are and are not payable with E/M visits can take some trial and error," explains Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center in Rochester, New York.

Remember: While matching CPT^® codes with their corresponding ICD-10 codes in the crosswalk might reduce denials, never choose a diagnosis from the crosswalk simply because it will be paid. The documentation must support the diagnosis.

Sometimes, there's no rhyme or reason as to why a particular set of diagnosis codes don't align with a given procedure. While a physician might perform a laminectomy to treat a diagnosis of spinal stenosis, often the stenosis is a result of another underlying condition, such as facet arthropathy. However, as you will see, the most appropriate diagnosis code is not always going to match up with a given surgical procedure.

For example: You're probably well aware that both M43.06 (Spondylolysis, lumbar region) and M48.06 (Spinal stenosis, lumbar region) correspond with code 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis], single vertebral segment; lumbar) in the coding crosswalk. However, when you look for M46.96 (Unspecified inflammatory spondylopathy, lumbar region) under 63047's crosswalk, you will come away empty-handed.

One of the first rules you learn as a certified coder is to code the underlying disease, not a symptom of the underlying disease. So, in the scenario where facet arthropathy results in spinal stenosis, you will want to be aware that an application of the facet arthropathy code M46.96 very well may lead to a denial, despite the fact that it is the most accurate code available.

Code both: If you wind up in the situation above, it's perfectly acceptable to code M46.96 as the primary diagnosis and M48.06 as the secondary diagnosis. However, the general rule is not to include any secondary diagnoses that exist as a result of the primary diagnosis. If the provider does not specify that one diagnosis is a result of the other, you may apply both codes.

Another example: Consider the lumbar spinal fusion procedure 22633 (Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace [other than for decompression], single interspace and segment; lumbar). Occasionally, a surgeon will perform this procedure on a patient to alleviate spondylolisthesis. However, if you cross-reference this code in the ICD-10 crosswalk, you will not find code M43.16 (Spondylolisthesis, lumbar region) as an applicable diagnosis code.

Look Out for E/M Crosswalks

If you cross-reference an E/M code in your coding crosswalk, you will find the same set of applicable diagnosis codes for each E/M code. The rules for cross-referencing diagnosis codes with surgical procedural codes are not the same when it comes to E/M visits, however.

"E/M services are paid as long as there is a medically necessary reason for evaluation and management," Cobuzzi says. "Most diagnoses (within reason) will support a standard E/M visit. However, it's important to keep in mind that not all diagnoses will support a higher-level E/M code."

Still, a payer may deny an E/M service for a diagnosis code that indicates the patient's underlying presenting problem. "Determining what diagnosis codes are and are not payable with E/M visits can take some trial and error," explains Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center in Rochester, New York.

Remember: While matching CPT^® codes with their corresponding ICD-10 codes in the crosswalk might reduce denials, never choose a diagnosis from the crosswalk simply because it will be paid. The documentation must support the diagnosis.