Orthopedic Coding Alert

Here's what to do if wrong location is due to extra vertebrae.

If your orthopedic surgeon performs a procedure on the wrong spinal level, you should hold off seeking any payment from Medicare. Future transmittals will instruct payers how to implement three final national coverage decisions (NCDs) specifying non-coverage.

As of Jan. 15, CMS specifies they will not cover surgical or other procedures when the MD performs:

- a procedure on the wrong body part;

- a procedure on the wrong patient; or

- the wrong procedure.

Bottom line: If you bill for procedures that meet any of the above stipulations and receive reimbursement, you could be facing a recoupment request at some future date.

"Hopefully this will force providers, OR staff, and other staff involved with the patient to take appropriate actions and verify they have the correct patient, the correct anatomical location, and are performing the correct procedure(s)," says Kathleen Nelson, CPC, professional coder of orthopaedics of Fletcher Allen Health Care in Burlington, Vt.

You need to understand what constitutes a "wrong" procedure.

The NCD for surgery on the wrong body part includes the following description: "A surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that patient including surgery on the right body part, but on the wrong location on the body; for example, left versus right (appendages and/or organs), or at the wrong level (spine)."

Keep in mind: If the MD decides to do a procedure on a different body part during the course of surgery, then you can still bill for this second surgical procedure.

"Doing an additional procedure versus doing an incorrect procedure are two completely different things," says Angela Good, CPC, surgery coder at Orthopaedic Institute of Ohio in Lima.

"Often surgeons are faced with unusual anatomy which requires expertise, technical challenges, etc.," Nelson agrees.

The NCD goes on to state: "Emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under this decision. Also, the event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae)."

Remember: "The surgeon's op note should reflect the reason for doing the additional procedure(s)," Good says.

For instance, spinal surgeons sometimes extend a decompression to an additional level if they discover evidence of spinal cord and/or nerve root compression that was not identified on pre-op studies. The surgeon would describe the situation in the op note. No special modifier applies. You would simply report the add-on code for the additional level (such as +63048, 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; each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]).

Note: You can appeal denials.

Know more: To view the NCDs, visit:

Wrong body part: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=222
Wrong patient: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=221
Wrong surgery performed on a patient: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=223