Neurosurgery Coding Alert

Shore up your diagnostic testing claims, medical necessity in 2004

You've assigned the right code to a magnetic resonance imaging (MRI) or other diagnostic test, confirmed that the surgeon's interpretation is in the file and clipped the ordering physician's MRI order to the patient's chart. Another pristine chart guaranteed to bring your practice quick payment, right?
 
Not so fast. If a physician who is excluded from the Medicare program ordered the diagnostic test in the first place, Medicare and other federal payers won't reimburse you for your work.
 
Surgery practices that own their own testing equipment and bill their own diagnostic tests must be careful that all ordering physicians are properly credentialed or they will be losing reimbursement.
 
Specifically, the U.S. Office of Inspector General's 2004 Work Plan states, "Under federal regulations, physicians who are excluded from federal healthcare programs are precluded from ordering, as well as performing, services for Medicare beneficiaries. During a current review, we identified a significant number of services that had been ordered by excluded physicians." Although this has been the case for years under OIG's Exclusion Program, a recent OIG review has launched it into the spotlight and made it a major concern for all physicians.
 
Surgery practices simply can't afford to have scores of diagnostic testing services denied just because an ordering physician was excluded from the Medicare program - and this is particularly frustrating when physicians don't self-disclose that they are excluded.
 
So how can you credential your facility's ordering physicians? The OIG maintains a database of excluded physicians. You can either download the entire database or search it using physician or business names. To access the database, visit http://oig.hhs.gov/fraud/exclusions.html.

Apply Modifier -59 With Caution

The OIG also intends to "determine whether claims were paid appropriately when modifiers were used to bypass National Correct Coding Initiative (NCCI) edits." Several modifiers - including -78 (Return to the operating room for a related procedure during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period) - can separate bundled NCCI (or global surgery) edits, but surgeons most frequently use modifier -59 (Distinct procedural service) to report two separate (but usually bundled) services provided on the same day, says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues in Fountain Valley, Calif.
 
For instance, 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar) includes laminectomy, facetectomy and diskectomy to prepare the interspace for posterior lumbar interbody fusion, and NCCI bundles it with 63047 (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; lumbar). The edit includes a "1" indicator, however, meaning you may use a modifier "to differentiate between the services provided" at different times or at different locations on the body. For instance, if the surgeon performs a decompression beyond that required for site preparation related to the posterior interbody fusion, or if she performs the laminectomy at a different level, you may report 63047 with modifier -59 appended.
 
"Physicians should be aware that when they append modifier -59, they are representing the fact that they have documentation on file that supports using it," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "Therefore, you should always be prepared to submit additional documentation that demonstrates that your procedures were separate and distinct from one another." If your documentation can't prove the separate nature of the bundled services, don't append modifier -59, Jandroep says.

Be Alert to Other Focus Areas

The 2004 Work Plan focuses on several other important areas for neurosurgeons and coders. These include proper coding for consultations (see Neurosurgery Coding Alert, October and November 2003) and other E/M services, as well as application of modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and care plan oversight codes (99374-99380 and G0181-G0182: Look to future editions of Neurosurgery Coding Alert for more information on these topics). And, as in past years, incident-to billing (that is, services billed by nonphysician practitioners incident-to the physician's services) remains a special area of OIG investigation.
 
The OIG Work Plan includes information about all of its investigative focus areas for 2004. You can access the full 90-page document by visiting the agency's Web site at http://oig.hhs.gov/. Search for "2004 Work Plan."