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Total Joint & Spine Reimbursement: Overcome 5 Big Challenges

Carolyn NeumannOn Oct. 16, 2013, Senior Manager, Coding & Coverage Access at Specialty Healthcare Advisers a subsidiary of Musculoskeletal Clinical Regulatory Advisers, Carolyn Neumann, CPC, presented a webinar titled "How to Overcome the 5 Biggest Reimbursement Challenges in Total Joint & Spine Coding."

Here are the challenges Ms. Neumann identified and discussed:

1. The language of coding. Coders must translate the description of procedures and services provided into five — soon to be seven — digit codes. The coder's language is based on various aspects of the procedure, including the surgical site and total services provided.

"Accurate coding is without a doubt the most important part of this coverage," said Ms. Neumann. "What we really need to do is think about all the code sets that factor into the ultimate reimbursement process."

The language of coding is important because denials are often based on simple errors made in translation. Payers now deny full claims for one small mistake and won't reimburse until the fixed claim is re-submitted.

2. Facilities and surgeons working together. Payers are now paying closer attention to what facilities bill versus what surgeons bill to make sure they match. Constant communication will help avoid inconsistencies that trigger denials or investigations.

"Surgeons should communicate authorizations to the facility and their documentation needs to be shared," said Ms. Neumann. "As our digital age improves, lack of communication will lead to a reimbursement nightmare when things don't match up."

Payers are also reviewing medical necessity more closely on facility claims, and auditors can retrospectively recoup reimbursement if they deem documentation insufficient to prove medical necessity.

3. Precise documentation. Especially as ICD-10 codes allow for a more detailed description of surgical procedures, surgical documentation will need to provide a more complete picture of services provided. Payers have specific guidelines for coverage and they may change these guidelines without warning.

"You want indications to match specifically with the diagnosis so it's part of the claim," said Ms. Neumann. "Policy changes may also happen without notice, so instead of six weeks of conservative therapy you might need to show six months. This is a bump in the road for reimbursement."

Ms. Neumann also discussed recent reverberations from the recent North American Spine Society Conference held in New Orleans where it was mentioned that medical necessity documentation for spinal fusion procedures will continue to be a focus of CMS's Program for Evaluating Payment Patterns Electronic Report. Different from other target areas, here the focus is not on coding or whether the patient should have been admitted, but whether the procedure was medically necessary at all. Medicare requires surgeons to document conservative non-surgical therapies such as supervised physical therapy, use of pain medication and life style modification, before ordering a spinal fusion.

4. Know payer policy. Ms. Neumann recommends assigning someone to check on payer policies and policy updates every three months and update physicians accordingly. Providers can also contract with insurance companies to provide certain services within state regulations.

"Know what you have agreed to, what you'll be paid and how it impacts the facility," said Ms. Neumann. "The revenue process should be shared with everyone. Know contracted reimbursements for providers and carve-outs."

She suggests devising a chart for the top five to 10 high volume procedures that details what most common payers require for reimbursement. "Minimally invasive surgical procedures are very popular and you want to make sure contracted guidelines allow for those procedures in the ASC," she said.

5. New technologies. Coding for new technologies can be a challenge because they don't have an assigned code; instead, coders use unlisted codes. T-codes and unlisted codes can throw up red flags for authorization of procedures and are difficult for many centers to achieve coverage.

"Spine and orthopedic surgery are expanding technology every day and we want to be able to provide access to those technologies for our patients when it is appropriate," said Ms. Neumann. "There is a process for receiving reimbursement on these codes that although time consuming, it's possible to be reimbursed on the facility and physician side. Prior authorization is essential when you are using these codes and it takes great physician commitment to go through the appeals process so the procedures are accurately reimbursed."

The tips Ms. Neumann gave for coding with unlisted and T-codes include:

•    Include any common procedures reported with T codes in your payer contracts
•    Know the code description in side and out
•    Create a special report to describe the procedure
•    Provide a "crosswalk" code for reimbursement value
•    Always take the prior authorization process through appeal

Download the presentation here.

Download a PDF of the presentation slides here.

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