Neurosurgery Coding Alert

A simple mistake in the Medicare payment schedule could be costing your neurosurgery practice hundreds of dollars a month in lost reimbursement. Thankfully, there are steps you can take to stop the loss, as well as to recover allowable payments from already-filed claims.

When reviewing your payments, check to be sure that Medicare and third-party insurers are reimbursing you in full for all add-on codes you-ve reported.

Here's why: The most recent version of the Medicare National Physician Fee Schedule Relative Value File incorrectly assigns a "2" modifier indicator to the "MULT PROC" column for several add-on codes that neurosurgery practices report frequently. The "2" indicator instructs payers to apply the multiple procedure payment reduction for the assigned code.

Under long-standing CPT and CMS guidelines, however, multiple-procedure payment reductions do not apply to any add-on or "modifier 51 (Multiple procedures) exempt" codes. The fee schedule amounts assigned to add-on codes are valued to reflect their status as "additional procedures." Any further reduction in reimbursement below the fee schedule amount represents an unwarranted devaluation of payment, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, manager of compliance education at the University of Washington Physicians.

Codes affected by the error include instrumentation procedures +22840 (Posterior non-segmental instrumentation-), +22842-+22844 (Posterior segmental instrumentation-), +22845-+22847 (Anterior instrumentation-), +22848 (Pelvic fixation-) and +22851 (Application of intervertebral biomechanical device[s]-), among others.

Example: When reported and paid correctly, 22840 will reimburse approximately $360, based on Medicare national averages. If, however, the payer incorrectly applies the multiple procedure reduction, your payment for 22840 will drop by half, to only $180. This can add up quickly -- especially over time, and when applied to multiple codes.

"This is a nightmare!" expresses Rena G. Hall, CPC, coder and auditor with KC Neurosurgery Group in Kansas City, Mo. "And it is not our fault that payers are processing the claims incorrectly."

If your payer is shortchanging you for add-on code reimbursement, be sure to appeal your payment. "We-ve had to appeal these claims every time we-ve gotten a payment from Medicare, Blue Cross/Blue Shield and a few other carriers," Hall notes.

If necessary, include a copy of the page in the CPT manual that shows the listing for the underpaid code, along with the "+" sign that specifies "add-on" status. In addition, you can include a copy of Appendix E of CPT, which shows a list of all CPT codes exempt from modifier 51 payment reduction. Explain to the payer that add-on codes are to be paid at their full valuation, regardless of how many additional procedures occur during the same operative session. You should stress that AMA guidelines from the "Introduction" of the CPT manual clearly state, "All add-on codes found in the CPT book are exempt from the multiple procedure concept."

Help is on the way: CMS updates the Physician Fee Schedule Relative Value File several times a year, as necessary, and will likely correct the mistake in upcoming editions. "I-ll be glad when it's corrected," Hall concludes.

In the meantime, stay vigilant by checking reimbursement for all the add-on codes you claim and protecting the payments your practice deserves.

For complete information on add-on codes, see "Make Add-On Code Claims Effortless," Neurosurgery Coding Alert, vol. 9, no. 2, pages 13-14.