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6 Ways to Avoid Denied Claims for Spine Procedures

Mona Kaul, chief coding and compliance officer of GENASCIS, which provides revenue cycle services and supporting technologies for surgery centers, discusses the following six ways ASCs can better avoid denied claims on spine procedures.

1. Physicians must dictate all necessary information.
When dictating, physicians should describe the surgical procedure in detail, allowing the coder to clearly visualize the entirety of the surgical encounter. This should include the type of approach used (endoscopic, percutaneous, open procedure, etc.), whether the procedure was anterior or posterior, the laterality and if the surgeon operated on more than one level.

Physicians should also describe any implants/graft used, and include details such as the type of implant and the number of units used (i.e., screws).

Finally, the physician's report should also establish medical necessity for the procedure, which needs to be defined through diagnosis codes.

2. Amend documentation in writing. If the coder has follow-up questions regarding the documentation within the medical record, clarification should be requested from the physician. All changes to the documentation must be made in writing and added to the patient’s record for possible future reference. Do not accept verbal direction as it may be subject to interpretation and is not part of the permanent medical record.

3. Differentiate the spine anatomy. Coders must be trained on spinal anatomy. In-depth knowledge of spinal anatomy will allow a coder to differentiate between procedures such as laminotomy (hemilaminectomy) and laminectomy (unilateral). Comprehensive understanding of the anatomy will also enable the coder to appropriately capture codes for spinal arthrodesis and instrumentation procedures.

4. Identify primary procedure and multiple procedures. Coders should code the primary procedure first and then include the add-on code for each additional procedure. Do not use the -59 modifier for add-on procedures. Add-on procedures are indicated in the CPT manual with a + sign. Certain spinal procedures may require the coder to append modifier -59 when a separately identifiable procedure has been performed.

5. Locating spinal procedures in the AMA codebook. Codes for the nervous system are available in two sections of the CPT codebook: 61000-64999 and 22010-22865. Coders should select the most appropriate code for the service rendered regardless of what section it is listed in.

For example, "Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar (eg, manual or automated percutaneous diskectomy, percutaneous laser diskectomy)" is 62287, while "Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2 [fusion])" is 22554.

6. Understanding rules for implant billing. Most arthrodesis procedures require the use of an implant, so it is important to note the CPT code for such procedures usually exclude the cost of the implant. Payors may require implants to be coded using separately identifiable HCPC level II codes.

Note: Some payors may require a copy of implant invoices to be sent with the claim. ASCs should identify which payors require such invoices to help ensure payors do not delay claims processing due to the lack of complete information.

Learn more about GENASCIS.

CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.

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