Orthopedic Coding Alert

Selective endoscopic diskectomy (SED) is a relatively new spinal procedure used to treat herniated disks. Proponents view SED as a less invasive treatment of herniated lumbar disks, and a better alternative to fusion for many cases of chronic back pain. SED allows the orthopedist to see the surgical site via the scope before excising the disk material.

Although clinical studies have proven its efficacy, coding and reimbursement are not yet up to speed. Correct coding and optimal payment involve educating the carrier(s), documenting the procedure and agreeing in advance to reimbursement levels with major carriers.

Clinical Example

Sherry Zeagler, director of clinical and ancillary services at The Louisiana Clinic, a multispecialty practice in New Orleans, provides an SED operative report for interpretation:

The patient, a middle-aged female, was diagnosed with a recurrent L4-L5 lumbar disk herniation (722.10 , displacement of lumbar intervertebral disk without myelopathy) and was placed under local anesthesia so she could respond to questions during surgery.

The L4-L5 area was injected with dye, and several intraoperative x-rays were taken as a needle was advanced into the region. When the surgeons determined the proper location of the needle, a guidewire with a dilator was inserted as the needle was removed. A cannula was inserted in place of the dilator, and an endoscope (discoscope) was advanced through the cannula, allowing the surgeon to visualize fully the affected lumbar region. Through the endoscope, the area was punched and shaved to remove the disk. The patient, conscious throughout the entire procedure, was asked to evaluate her leg and back pain, and reported that it had totally dissipated. A minimal incision, negligible blood loss and lack of general anesthesia contributed to the patients minimal recovery time, and she was released later the same day.

Unfortunately, coding SEDs correctly and ensuring reimbursement is not an easy task. Because no CPT Code describes an SED, coders should anticipate using an unlisted procedure code when submitting a claim. Choices are 29909 (unlisted procedure, arthroscopy) or 64999 (unlisted procedure, nervous system). According to Eric Sandham, CPC, compliance educator of the Central California Faculty Medical Group in Fresno, Calif., either code will have the same result. Both codes will spit the claim out of automatic processing for manual pricing. If the coder doesnt submit an operative report, the carrier will request one, Sandham says.

Coders should include the operative report and a brief letter from the surgeon explaining in lay terms what he or she did in the operating room. In the letter, the surgeon should cite an analogous code (in the previous example, 63030, laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]), which accomplishes the same result through a different operative approach (open). The letter should describe how the SED procedure is similar to and how it differs from the laminotomy.

Also, coders should look for or ask the surgeon to provide articles from medical journals that cite the efficacy of SED procedures and submit them with the claim. As with any new or experimental procedure, carriers need to be convinced of its medical necessity, even when it means a shorter hospital stay and less follow-up care for the patient. The physician should also indicate in his letter why the SED approach was the better option for this patient.

Avoid Miscoding

Zeagler says she has been submitting 29909 and billing for an intraoperative diskography using 62290 (injection procedure for diskography, each level; lumbar) and 72295 (diskography, lumbar, radiological supervision and interpretation). This has resulted in denials and in reduced reimbursements, Zeagler says, because the carrier would downcode and reimburse for a lesser code, usually 62287 (aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar [e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy]), which does not describe what the surgeon is doing.

Zeagler adds that the practice has also tried to code the SED with 63030 along with 62290 and 72295. We still have denials no matter what, she says.

Correctly Coding the Surgery

Part of the explanation for Zeaglers rejections lies in the combination of codes being applied. Per the American Academy of Orthopaedic Surgeons Complete Global Service Data Guide, 63030 includes intraoperative supervision, positioning and interpretation of imaging or monitoring equipment by operating surgeon or assistant(s), including the diskogram (72295). And, because the injection of contrast material (62290) is a component of the diskogram (72295), both codes are considered bundled with the major procedural code (63030). The result is either that the carrier is rejecting the entire claim or that the unbundling is causing the claim to pend.

As far as the carrier downcoding the surgery to 62287, many insurance carriers incorrectly lump all minimally invasive lumbar diskectomy procedures under this code. Because CPT does not provide codes that describe many of the newer surgical technologies, carriers often look for a way to pigeonhole procedures to facilitate claims processing. For the surgeon, this often results in poor reimbursement for technically demanding procedures that require specialized surgical skills.

Consider a Pre-emptive Strike

A proactive step in securing payment for SEDs involves contacting the payer in advance and determining in writing its payment guidelines for the service. As is always helpful when working with carriers, attempt to establish a phone relationship with a person in a decision-making capacity.

Provide the carrier with ample information as to why SEDs are the optimal choice for some patients, and outline, if possible, how the carrier stands to benefit by reimbursing for these surgeries. This benefit can be a shorter length of stay for the patient, speedier recovery time, and more satisfactory results that eliminate the need for future surgeries.