Neurosurgery Coding Alert

Anterior cervical diskectomy with fusion (ACDF) can be a challenge to code correctly because it involves multiple CPT codes that must often be in a specific sequence when submitting a claim. For some payers, failure to list the codes appropriately could lead to reduced reimbursement. By applying the rules that govern multiple procedures, including the application of modifier -51 (multiple procedures), practices can ethically maximize payment for ACDF and other multicode surgeries.

Up to five codes may be appropriate, as follows:

22554 arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); cervical below C2

22585 each additional interspace (list separately in addition to code for primary procedure)

63075 diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace

63076 each additional interspace (list separately in addition to code for primary procedure)

20931 allograft for spine surgery only; structural

20938 structural, bicortical or tricortical through separate skin or
fascial incision.

During the procedure, the surgeon enters through the back of the neck to access the spine, removes a disk, grafts in bone harvested from the patient's body or a bone bank, and resupports the neck. In most cases, five of the above codes are used to report the surgery and, depending on the number of spinal levels fused, several codes may be billed more than once (see below for examples).

When you report multiple-procedure surgeries, individual codes should not be listed on the claim form in numerical order or in the order the procedures were performed or listed on the operative note. They should be listed according to their assigned relative value units (RVUs).
 
Multiple-procedure claims are never paid at 100 percent. Instead, the payer reasons that many of the component services"" that make up the physician's total effort when performing a particular service" such as any inherent E/M or the surgical approach and closure are already paid as part of the primary procedure and do not require separate reimbursement. In other words the multiple-procedure reduction is the payers' way of avoiding redundant charges for shared work under two or more codes.
 
In the past some payers reimbursed 100 percent for the initial CPT procedure listed 50 percent for the second and 25 percent for the third and all subsequent procedures. Since Jan. 1 1995 however payment for the second through fifth procedures has been fixed at 50 percent of the total allowable RVUs for the code with the primary procedure paid in full.
 
This is important because if the primary (i.e. highest- valued) procedure is not listed first a lower-paying code may be fully reimbursed while the primary procedure is paid at a reduced rate lowering overall reimbursement says Laureen Jandreop OTR CPC CCS-P CPC-H CCS owner and CPC trainer for A+ Medical Management and Education in Absecon N.J.
 
For instance procedure X is valued at 30 RVUs and procedure Y is valued at 20 RVUs. If procedure X is paid in full and procedure Y is reduced by 50 percent per multiple-procedure guidelines total payment is 40 RVUs (30 + 20/2 = 40). If procedure Y is paid in full however and X (the higher-valued procedure) is reduced by 50 percent payment falls to 35 RVUs (20 + 30/2 = 35). Although some payers use software that automatically orders codes according to RVUs not all do. Therefore it is important to find and compare RVUs for all codes subject to multiple-procedure reductions.
 
The Fee Schedule reveals that the codes describing ACDF should be listed on the claim form in the following order:

 

63075: 36.97 RVUs
 

22554: 36.07 RVUs
 

22585: 9.45 RVUs
 

63076: 6.99 RVUs
 

20931: 3.13 RVUs.

To ensure proper reimbursement use the same technique for all multiple-procedure surgeries. If you use billing software that orders your codes automatically be sure to "spot check" the software's method of listing multiple codes especially for your most commonly billed code combinations Jandreop says. Inconsistent or miswritten software could reduce your fees unnecessarily.
 
Step Three: Determine If Modifier -51 Is Necessary

When providing multiple procedures to the same patient on the same date of service you may need to append modifier -51 to the second and subsequent procedures. As noted above some payers including many Medicare carriers use software that automatically detects second and subsequent procedures and reimburses them accordingly thus making modifier -51 unnecessary. If possible request the payer's instructions in writing suggests 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.
 
In situations where modifier -51 is appropriate it must be appended to the correct i.e. subsequent or additional   code. Also 22585 and 63076 are "list in addition to" or "add-on" codes that are used with the primary procedure code (22554 and 63075) to report each additional interspace beyond the first. According to CPT such add-on codes are modifier -51 exempt and should not encounter a further multiple-procedure fee reduction. Therefore for payers that require modifier -51 your claim should appear as follows:

 

63075 (paid in full)
 

22554-51 (reduced by 50 percent per multiple- procedure reduction guidelines)
 

22585 (x the number of additional interspaces: paid in full for each unit billed)
 

63076 (x the number of additional interspaces: paid in full for each unit billed)
 

20931 or 20938 as appropriate (paid in full per modifier -51 exempt guidelines).
 
 
Do not reduce fees for the second and subsequent procedures when appending modifier -51. Payers will reimburse according to their fee schedule Sandham says as long as your charge is not below their amount.

Step Four: Check the EOB
  
 
When receiving payment for multiple-procedure claims always check the explanation of benefits (EOB) to be sure that payment for the lesser-valued procedure(s) is reduced and that the highest-valued procedure is reimbursed at its full rate Jandreop says. Also be sure that add-on codes are not further reduced. If the payer has reduced the fee for any procedure inappropriately appeal.