Neurosurgery Coding Alert

Proper coding for neurosurgical procedures and practices requires up-to-the-minute information, experience and skill, as well as dedication to documenting, representing, and communicating precisely what transpired between a neurosurgeon and a patient to insurance carriers. In an effort to recognize the level of professional excellence and the great effort given by coders to provide quality service, the American Health Information Management Association (AHIMA) has revised and released its Standards of Ethical Coding.

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, says that the AHIMA guidelines codify a portion of the Health Care Financing Administration (HCFA) policy that was not in writing previously: If it wasnt documented, it wasnt done.

If a fluoroscopy was performed but not documented, it should not be billed, Sandham says. The AHIMA guidelines give coders a professional responsibility to help ensure such documentation and to keep abreast of the latest coding changes. For example, a coder should know that he or she can bill a fluoroscopy (76005-26) in addition to a facet joint injection (64470). A coder following the AHIMA guidelines is likely to have this information.

Karen Duane, CPC, coding specialist for the Barrow Neurological Institute, which has 29 neuroscientists of various specialties including nine neurosurgeons in Phoenix, Ariz., who previously worked in the Arizona Medicare fraud department, considers the revised AHIMA standards to be a positive step forward for coders.

Duane says that coders occasionally are placed in the potentially uncomfortable position of educating neurosurgeons about coding practices. A neurosurgeon who is aware of the new AHIMA guidelines and knows that his or her coder is following these high standards should have greater confidence in the information a coder presents when billing for services provided.

AHIMAs Revised Standards of Ethical Coding

AHIMAs new guidelines present 10 points that coders should remember in all aspects of their profession. These 10 guidelines state:

1. Coding professionals are expected to support the importance of accurate, complete and consistent coding practices for the production of quality healthcare data.

2. Coding professionals in all healthcare settings should adhere to the ICD-9 coding conventions official coding guidelines approved by AHIMA, HCFA, the American Hospital Association and the National Center for Health Statistics; the CPT rules established by the American Medical Association; and any other official coding rules and guidelines established for use with mandated standard code sets. Selection and sequencing of diagnoses and procedures must meet the definitions of required data sets for applicable healthcare settings.

3. Coding professionals should use their skills, their knowledge of the currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes.

4. Coding professionals should assign and report only codes that clearly and consistently are supported by physician documentation in the health record.

5. Coding professionals should consult physicians for clarification and additional documentation prior to code assignment when there is conflicting or ambiguous data in the health record.

6. Coding professionals should not change codes or the narratives of codes on the billing abstract so that the meanings are misrepresented. Diagnoses or procedures should not be included or excluded inappropriately because the payment or insurance policy coverage requirements will be affected. When individual payer policies conflict with official coding rules and guidelines, these policies should be obtained in writing whenever possible. Reasonable efforts should be made to educate the payer on proper coding practices to influence a change in the payers policy.

7. Coding professionals, as members of the healthcare team, should assist and educate physicians and other clinicians by advocating proper documentation practices, further specificity, resequencing or inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity and the occurrence of events.

8. Coding professionals should participate in the development of institutional coding policies and should ensure that coding policies complement, not conflict with, official coding rules and guidelines.

9. Coding professionals should maintain and continually enhance their coding skills, as they have a professional responsibility to stay abreast of changes in codes, coding guidelines and regulations.

10. Coding professionals should strive for the optimal payment to which the facility is legally entitled, remembering that it is unethical and illegal to maximize payment by means that contradict regulatory guidelines.