1. The language of coding. “There is no defined definition of ‘minimally invasive,'” Ms. Neumann said. “Taking that to the reimbursement process, coding and coverage, the language is vague.” The vagueness can be a barrier to reimbursement for minimally invasive spine surgeries performed in ASCs.
2. Coverage concerns. ASC leaders should know payer-specific policies and how that affects MISS reimbursement. Ms. Neumann recommended making payer mix charts with specific policies, including pre-authorization requirements, covered procedure, conservative therapy requirements, imaging requirements and indications or contraindications to ensure proper steps are taken for every surgery.
3. Place of service and different payers. “Medicare is very concerned” with place of service, Ms. Neumann said. “Private payers have a lot more leeway.” Private payers follow state regulations and their own policy guidelines to determine place of service for procedures. ASCs should initiate contracts with top MISS procedure payers in their area, she said.
Ms. Neumann also recommended tracking MISS procedure outcomes, which can help contract negotiations when an ASC tries to bring in a new payer for MISS procedures.
4. Know your contracted payer guidelines. Just because there is a valid code does not mean a procedure is covered. “Coding and coverage are two different issues,” Ms. Neumann said. She recommended reading all coverage guidelines, especially paying attention to technologies, to make sure everything involved in a procedure is covered.
5. Documentation. Detailed documentation is especially important for MISS procedures because it has a major impact on reimbursement. “People have trouble getting that from surgeons,” Ms. Neumann said, but the use of pop-ups in electronic health records can make detailed documentation easier.
6. Spinal instrumentation. When it comes to coding, it is important to note what spinal levels are being taken out and what levels are being put in.
7. Surgical modifiers. Code modifiers can have a major impact on reimbursement, according to Ms. Neumann. Coders should watch code descriptions closely, especially for bilateral procedures. Using the right code modifier can have a major impact on reimbursement levels.
8. What codes to use for MISS procedures. “What matters is what you do,” Ms. Neumann said, since minimally invasive does not have a good, set definition. For instance, if a physician uses his or her eyes or a microscope to visualize a procedure, the code considers that an open, not minimally invasive, procedure, she explained.
9. New technology and procedures. While the Food and Drug Administration may say a technology is safe and effective for use, CMS and private payers are on a different page. In order to have a technology be covered, CMS looks for it to be “reasonable and necessary,” Ms. Neumann says. “It’s a whole different discussion.” She noted that many new technologies can be correctly reported with a “T” code or a generic “unlisted” code.
10. Surgeons and facilities working together. Coordination between ASCs and surgeons is key to receiving the right reimbursement. Many payers are coordinating their reimbursements to include both physician and facility claims. If reported codes do not match, the entire claim — for the physician and the facility — can be denied.
