Outpatient Facility Coding Alert

Published on Mon Oct 15, 2012 PDF

Payer rules keep changing, so keep up with what they want.

Getting appropriate reimbursement for spine surgery has challenged physicians and coders for years, but recouping payment becomes even trickier when payers routinely change their own guidelines and policies. Your best defense is a good offense: Ensure surgeons thoroughly document each component up front to get the pay they deserve.

Catch Up With Ever-Changing Guidelines

Payers use different sets of guidelines for covering spine surgery, which means you must be familiar with each insurer's policies.

Example: Some payer policies state that if there is no documented pain relief after two injections, no further injections will be considered medically necessary at that level, says Sarah Goodman, MBA, CHCAF, CPC-H, CCP, FCS, president of the consulting firm SLG, Inc., in Raleigh, N.C. Others preface that if the first two injections are done without fluoroscopic imaging and they have failed to provide documented pain relief, then a third injection must be performed under fluoroscopic guidance.

Think "Documentation" Through Every Step

One of the top reasons payers deny spinal surgery claims is not proving the procedure was medically necessary. Your best way to avoid that accusation is to encourage clear documentation of each phase of treatment.

Medications and simple therapies: Sometimes over-the-counter or prescription medications such as naproxen (Aleve®) will help relieve a patient's back pain. Rest, heat or ice applications, and gentle stretching might be other first steps of treatment.

Failed physical therapy: If basic medications and other first-level treatments fail, the physician might prescribe a more intense, focused physical therapy plan over a period of several months.

Spinal injection trials: The next step in treating chronic back pain could be administering epidural steroid injections. Choose your codes based on whether the physician injected the cervical/thoracic or lumbar/sacral spine. Common options could include:

• 64479 -- Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level
• +64480 -- ... cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
• 64483 -- Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level
• +64484 -- ... lumbar or sacral, each additional level (List separately in addition to code for primary procedure).