Orthopedic Coding Alert

You can pretty much give up on billing spinal manipulation with other spinal surgeries, thanks to version 13.3 of the Correct Coding Initiative (CCI), effective Oct. 1.

Last month, we gave you the great news that the CCI is revoking the edit that bundled cervical discectomy code 63075 with cervical arthroplasty code 0090T. But CCI delivered more than just good news this round.

Beginning Oct. 1, spinal manipulation code 22505 (Manipulation of spine requiring anesthesia, any region) becomes a component of most of the codes in the spinal surgery section from 22532 to 22865. A modifier will do you absolutely no good in dealing with this new edit, but on the brighter side, many practices were already including 22505 in their spinal procedures.

"If there is a spinal fracture that is treated in an open fashion, that would automatically include the manipulation," says Kathleen F. Nelson, orthopedic surgical coder with Fletcher Allen Health Care in Vermont. "Therefore, 22505 would not be submitted separately."

Also effective Oct. 1, CPT codes 12001-12007 (simple repair of superficial wounds) become components of four dozen codes, each from the musculoskeletal system section.

In a nutshell: Thanks to CCI, you probably can't bill for one of those superficial wound repair codes at the same session as a deep excision, a tissue graft, a radical tumor resection, a deep incision and drainage (I&D), a radical resection, a spine surgery, or a lesion excision.

Layered wound closure codes (12031-12037 and 12041-12047) will also become components of most of the same surgical codes.

Complex wound repair codes 13100-13132 (except for the add-on codes) are also slated to become components of a few dozen surgical codes.

Although most surgeons weren't separately billing the simple closure, some may be dismayed by the layered closure bundle. "Most of my surgeons already consider the -simple- repair inclusive of the more restorative treatment anyway and do not submit separately," Nelson says, "But the layered closure may be an issue because of the degree of difficulty involved with the closure. We will have to wait and see, case by case."

Similarly, superficial facial wound repair codes 12011-12018 became components of a number of surgical codes, including several facial fracture care codes. Layered facial wound repair codes 12051-12057 and complex facial wound repair codes 13150-13152 will be components of many of the surgical (and facial fracture care) codes as well.

You can use a modifier to override those edits, but be prepared to justify the need for a separate wound repair.

CPT codes 12020-12021, for treatment of superficial wound dehiscence, also became components of about 58 surgical codes. You can use a modifier to override these edits.

In other CCI news, the controversial medically unlikely edits (MUEs) are taking a big step into the unknown starting in January -- and your claims could wind up on the chopping block as a result.

MUEs will limit the number of units of a particular code your doctor can bill. For instance, if your doctor tries to bill for amputating more than six digits in one session, the edits may kick in, says William Rogers, MD, head of the Physician Regulatory Issues Team at CMS. Removing six fingers in one session is "not impossible, but unlikely to be seen in a normal practice," he says.

Coming up with edits based on likely clinical scenarios is trickier than crafting ones based on anatomic impossibility, Rogers concedes. But CMS has been using a "very inclusive and consensus-driven" policy to craft the new edits.

The bottom line: Medicare is processing a billion physician claims a year, on a budget of less than $1 per claim. "You can't afford to have every claim individually reviewed," Rogers says. So making the claims pass through a computerized screen is the only way to prevent "unscrupulous people" from billing for whatever they want.

Now, you can never use modifiers to override the MUEs that are based on anatomic impossibility. Some physician groups have suggested allowing modifiers for these new "clinical judgment" MUEs. For now, though, if you have a case that is true but seems unlikely, you can contact your carrier ahead of time, CMS officials have suggested.

Why you won't find them anywhere: Physicians asked CMS to make the list of MUEs public. But CMS responded that some providers could misuse that list to bill for the maximum possible number of units of a particular code, avoiding the edits but still billing fraudulently.

So you should scrutinize your Explanations of Benefits (EOBs) to look for remark code N362. This remark code represents units of service "exceeding an acceptable maximum" and may mean your claim has fallen afoul of the MUEs.

Remember, you can't bill the patient for services denied due to MUEs.