Neurosurgery Coding Alert

Here's how to capture pay if wrong location is due to extra vertebrae.

If your neurosurgeon performs a procedure on the wrong spinal level, you should hold off seeking any payment from Medicare.

Future transmittals will instruct payers how to implement three final national coverage decisions (NCDs) specifying non-coverage. As of Jan. 15, CMS specifies it will not cover surgical or other procedures when the physician performs:

- a procedure on the wrong body part

- a procedure on the wrong patient

- the wrong procedure.

Bottom line: If you bill for procedures that meet any of the above stipulations and receive reimbursement, you could be facing a recoupment request at some future date.

-If the doctor made a mistake, the patient should not have to pay for it, nor should the insurance company,-says Christine M. Bitner, CPC, CPC-I, chart abstraction specialist at HCA Physician Services in Brentwood, Tenn.

-Hopefully this will force providers, OR staff, and other staff involved with the patient to take appropriate actions and verify they have the correct patient, the correct anatomical location, and are performing the correct procedure(s),- says Kathleen Nelson, CPC, professional coder at Fletcher Allen Health Care in Burlington, Vt.

Attention to detail -is required to provide the appropriate care to a patient, and that includes putting into practice guidelines for confirming the service the neurosurgeon provides is the service the patient needs,- says Rena Hall, CPC, billing/insurance specialist for The Kansas City Neurosurgery Group, LLC in Missouri.

You need to understand what constitutes a -wrong- procedure.

The NCD for surgery on the wrong body part includes the following description: -A surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that patient including surgery on the right body part, but on the wrong location on the body; for example, left versus right (appendages and/or organs), or at the wrong level (spine).-

Keep in mind: If the physician decides to do a procedure on a different body part during the course of surgery, you can still bill for this second surgical procedure.

Doing an additional procedure versus doing an incorrect procedure are two completely different things,Bitner says. An additional procedure would have supporting documentation whereas due to lack of medical necessity, the -incorrect- procedure is questionably billable, Hall says.

-Often surgeons are faced with unusual anatomy which requires expertise, technical challenges, etc.,- Nelson agrees.

The NCD goes on to state: -Emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under this decision. Also, the event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or the discovery of an unusual physical configuration (e.g.,adhesions, spine level/extra vertebrae).-

Remember: The surgeon's op note should reflect the reason for doing the additional procedure(s), Bitner says.-You should also have a diagnosis to support it,- she says.

For instance, spinal surgeons sometimes extend a decompression to an additional level if they discover evidence of spinal cord and/or nerve root compression that was not identified on pre-op studies. The surgeon would describe the situation in the op note. No special modifier applies. You would simply report the add-on code for the additional level (such as +63048, Laminectomy,facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [e.g., spinal or lateral recess stenosis]),single vertebral segment; each additional segment,cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]).

Note: You can appeal denials.

Know more: To view the NCDs, visit:Wrong body part: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=222

Wrong patient: http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=221

Wrong surgery performed on a patient: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=223.