Neurosurgery Coding Alert

If you've ever filed a claim using an unlisted-procedure code, you know how much effort is involved. To ensure that the surgeon's work (and the coder's work in preparing the claim) is properly rewarded, our experts offer you the following three tips.

Tip 1: Describe the Procedure in Plain English

Anytime you file a claim using an unlisted-procedure code (for example, 22899, Unlisted procedure, spine; or 64999, Unlisted procedure, nervous system), you must submit a full operative report to describe the procedure or service. But if you're looking for fair reimbursement, the operative notes alone won't be enough. You've got to include a separate report that explains in simple, straightforward language exactly what the surgeon did.
 
"There's no 'standard' fee for an unlisted-procedure code," says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. "Insurers consider claims on a case-by-case basis and determine payment based on the documentation you provide. Unfortunately, claims reviewers, especially at lower levels, do not have a uniformly high level of medical knowledge, and surgeons don't always dictate the most accessible notes." Part of the coder's job in preparing the claim is to act as an intermediary between the surgeon and the claims reviewer, providing a description of the procedure in layman's terms.
 
"If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved," says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Brick, N.J. Be careful to avoid or explain medical jargon and difficult terminology. And, if appropriate, you may include diagrams or photographs to better help the insurer understand the procedure.
 
For example, CPT includes no specific code to describe open-door laminoplasty, so you should report the procedure using 64999. When describing this procedure, you should use the surgeon's operative notes as a guide, stressing the main points of the operation and why it was necessary. A sample narrative might read:

Patient has spinal stenosis (723.0, Cervical), a narrowing of the spinal canal that compresses the spinal cord, which leads to pain, numbness and lost motor abilities.
 
To preserve spinal stability, the surgeon chooses "open-door" laminoplasty, rather than decompressive laminectomy, to relieve pressure on the spinal cord.
 
Following incision, the surgeon removes the tips of the spinous process (the rear-facing bony protrusion of a vertebral segment) at the affected level. He then cuts through the lamina (the bony arch surrounding the spinal cord) on one side of the spinous process and notches the lamina on the opposite side to create a "hinge." The surgeon opens the "hinge," thereby releasing pressure on the spinal cord. The surgeon then places bone grafts in the space left by the "open door," which he secures in place with titanium plates.

"A little extra effort to write a clear description of the procedure can go a long way toward improving your reimbursement," Cobuzzi says.

Tip 2: Compare the Procedure to an Existing Code

One way an insurer may make a payment determination for an unlisted-procedure claim is by reading your procedure description and comparing it to a similar, listed procedure with an established reimbursement value, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. For example, if the surgeon performs an unlisted endoscopic procedure, the insurer may compare it to an equivalent open procedure for which CPT provides a code. Generally, the insurer will judge the endoscopic procedure less invasive and less difficult than the open procedure and  will accordingly pay less for the former. But the comparison gives the insurer a baseline from which to determine a payment value.
 
Rather than allow the insurer to determine which is the "next-closest" code, you should explicitly reference the nearest equivalent listed procedure in your explanatory note. "After all, the operating surgeon is best equipped to make this determination," Jandroep says.
 
You should also specifically note how the unlisted procedure differs from the next-closest listed procedure, Sandham says. For example, was the claimed unlisted procedure more or less difficult than the "comparison" procedure? Did it take longer to complete? Was there a greater risk of complication? Will the patient require a longer recovery and more postoperative attention? Did it require special training, skill or equipment? Any of these factors can make a difference in the level of reimburse-ment you may expect.
 
For example, CPT does not include a code to describe laminotomy and excision of herniated thoracic disk (the only thoracic codes correspond to transpedicular or costovertebral approach). CPT, however, does include codes to describe cervical (63020) and lumbar (63030) excisions. To report thoracic laminotomy, you may cite 64999 and include an explanation with the claim stating, "Surgeon performed laminotomy with diskectomy, similar to that described by 63020 (Laminotomy [hemi-laminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical), but occurring in the thoracic region. And, the work involved was roughly 10 percent greater than that described by 63020."

Tip 3: Enlist Outside Help

Medical technologies often evolve faster than the CPT manual, and the manufacturers of new drugs and equipment have a vested interest in making sure that carriers pay physicians for using the latest innovations, even if a CPT code doesn't exist to describe them. If the physician finds himself using equipment and techniques for which CPT does not provide a code, you may be able to enlist the aid of the manufacturer in receiving appropriate reimbursement.
 
Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies, Jandroep says. And they are sometimes instrumental in gaining approval for new CPT codes to describe previously unlisted procedures, as well. (For example, Guilford Pharmaceuticals, manufacturer of Gliadel Wafers, sponsored the application for 61517, which was added to CPT 2003 to describe implantation of intracavitary chemotherapy agents.)
 
Use caution when applying manufacturers' suggestions, however. Remember: You are responsible for the accuracy of your claims, and you should never misrepresent a claim to gain payment. Stick to unlisted-procedure codes when no other code describes the procedure the surgeon performed and always provide ample documentation to justify the claim's necessity.