Neurosurgery Coding Alert

Auditors found over $260 million in errors among neurosurgery codes.

It's no secret that neurosurgery coders have immeasurably challenging jobs, reading intricate nerve, spine, and brain procedure notes and translating them into codes for billing purposes. But with coding not being an exact science, errors are bound to happen - and Medicare auditors are sure to find them. That's exactly what happened when reviewers looked over scores of 2016 claims and calculated the many issues that prompted overpayments and underpayments last year, prompting carriers to request potentially millions in paybacks.

Background: CMS released its "Appendices for the Medicare Fee-for-Service 2016 Improper Payments Report" in December as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the most egregious errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found an 11.7 percent improper payment rate among Part B claims during 2016, with the vast majority of those being classified as overpayments to providers.

The majority of Part B errors were categorized as such due to insufficient documentation (totaling $5.5 billion in errors), while incorrect coding was also a major error source (costing $2.7 billion in errors). Medical necessity and no documentation errors were also seen among Part B claims - and neurosurgeons were not immune to the issues that the auditors found.

Neurosurgery Services Logged Over $260 Million in Errors

When the government scrutinized neurosurgery procedures, the CERT auditors found that spine, brain and nerve services were responsible for over $260 million in medical necessity errors. This means that when the auditors asked for documentation to support these claims, they could not find proof that the services were medically necessary. The following were among the most problematic medical necessity errors:

Here's How to Avoid These Issues

Unfortunately, many of the practices that CMS found to be in error will find letters from their payers asking for money back, because if an insurer finds a lack of medical necessity, the claim will likely be considered not payable. Consider the following examples of improperly coded neurosurgery claims so you can avoid a spot in CMS' next improper payment report, and you can therefore hang on to your income.

Example 1: You report 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) for a facet joint injection to one lumbar level. The neurosurgeon documents the following:

The patient was prepped and draped in a sterile fashion. The needle was inserted through the skin, after which it was advanced into a lumbar facet space using fluoroscopic guidance. A mixture lidocaine and cortisone was injected into the affected lumbar joint, after which the needle was withdrawn and hemostasis was achieved.

Do  you  see  the  problem  with  this  code  selection? The operative note definitely does not establish medical necessity for the procedure. The facet joint injection policy for Part B payer Wisconsin Physicians Service Insurance Corporation states, "Required elements of the note include a description of the techniques employed, nerves injected and sites(s) of injections, drugs and doses with volumes and concentrations as well as pre and post-procedural pain assessments."

Therefore, this neurosurgeon should have described which anatomic area was injected (in the example note, it only refers to "the lumbar facet space" rather than the specific area), and he should have documented the needle used and the medication injected. For instance, "The L45facet joint was identified under fluoroscopic guidance. Using a 22-gauge spinal needle, 3.25 inches were advanced into the facet joint and the nerve was injected with 40mg Depomedrol and Marcaine .25%."

The physician does not demonstrate medical necessity for reporting 64493, and if the payer requested the notes, it would most likely request a repayment of the approximately $175 that Medicare pays for this service in the outpatient setting.

Example 2: The neurosurgeon meets with a new patient who was referred following a seizure. The practice performs EEG monitoring for 78 minutes, and reports one unit of 95812 (Electroencephalogram [EEG] extended monitoring; 41-60 minutes) and one unit of 95813 (Electroencephalogram [EEG] extended monitoring; greater than 1 hour) along with modifier 59 (Distinct procedural service). The documentation describes the EEG in detail and includes the neurosurgeon's assessment of the results. It also clearly indicates the time spent on the monitoring (78 minutes).

Do  you  see  the  problem  with  this  code  selection?  The note appears to be thorough enough to support the physician's claim for EEG monitoring, but the practice should only have reported 95813 to reflect the 78-minute test. Reporting both 95812 and 95813 constitutes upcoding.

"When a code is indented in the CPT^® manual, as 95813 is, that suggests that it is a variation of the code above it, and can replace the previous code - not be billed in addition to it," says Terri  Orcala of Orcala Billing in Kansas City, Mo. Because it doesn't have a "plus" symbol in front of it, that means 95813 is not an add-on code, and cannot be billed along with 95812 when the time threshold passes 60 minutes.

Some coders make this mistake, because although the Correct Coding Initiative (CCI) does bundle 95812 into 95813, the guidelines state, "A modifier is allowed in order to differentiate between the services provided." The coder in our example above did append modifier 59 to the claim and likely collected for both codes, but an audit of the records would demonstrate that the documentation only justifies the practice collecting for 95813, and it would have to pay back the approximately $328 that it collected for 95812.

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/AppendicesMedicareFee-for-Service2016ImproperPaymentsReport.pdf.