Spine and pain coding today: Top 7 challenges

Written by Anuja Vaidya | June 15, 2015 | Print  |

In a webinar hosted by Becker's ASC Review on June 3, Lisa Rock, president of National Medical Billing Services; Jessica Edmiston, BS, CPC, CASCC, AHIMA, approved ICD-10-CM trainer, senior vice president, performance review at NMBS; Tamara Wagner, BS, CPC, vice president, performance review at NMBS; and Alison Kuley, CPC, spine coder at NMBS; discussed the most pressing challenges in coding for spine and pain management procedures today.

According to Ms. Rock, navigating the healthcare landscape, particularly with regard to coding, is very difficult right now. Here are seven of the toughest issues in spine and pain coding:

1. Anatomy. The first challenge for spine and pain coders is knowing the anatomy of the spine, noted Ms. Wagner. Coders need to know the full anatomy of the spine so as to fully understand the operative notes. "They need to know the approach the surgeon is taking in the procedure as well as proper level and correct diagnosis assignment," she said. "Coders need to be familiar with facet joints as well as medial branch nerves and they need to understand which nerves innervate which joints."

2. Documentation challenges. In spine and pain coding, half the battle is obtaining accurate documentation, said Ms. Wagner. Typically, there are inconsistencies within the operative report such as discrepancies between the procedure heading and the actual description. Also, information may be missing that affects revenue. "An example of documentation challenges in spinal decompression surgery — the specific  nerves decompressed need to be documented properly as each additional level of decompression can increase revenue," said Ms. Kuley.

3. LCDs, NCDs and payer policies. Spine and pain coders need to use CMS' local and national coverage determinations. These policies are being updated more and more frequently and thus, it is important that coders use the most up-to-date LCDs and NCDs, said Ms. Wagner. In addition, payer policies change quite frequently as well, and today, more information is needed to show medical necessity than in the past.

4. Medical necessity. As mentioned above, payers are requiring more documentation to support medical necessity than diagnosis. "For example, some payers now need to know the specific percentages of pain relief that the patient has undergone as well as whether they have had prior physical therapy or an MRI," said Ms. Wagner.

5. Applying NCCI edits. According to Ms. Rock, it is important that coders check managed care contracts to ensure they are using the correct edits — the National Correct Coding Initiative edits or based on CPT guidelines. "Carriers sometimes put in whatever edits they prefer to use into the contract," said Ms. Rock. "Whether you choose to follow NCCI edits for all payers or not, it is important to establish a company policy. You must understand how your carriers are adjudicating claims and then you will be able to challenge them if necessary."

6. Implants. This is another challenging area for coders, said Ms. Kuley, particularly when it comes to the use of P-stim implants. These implants are being used more often and there is a great deal of confusion regarding how to code for them. Vendors often suggest coding for these implants like you would code implantable stimulators, however, these implants are placed behind the ear. "They are not actually implanted," she said. "Don't be afraid to ask vendors for documentation from official sources to support their coding advice and be sure to research your payer policies or CPT coding policies regarding any new technologies that you are thinking of adding to your ASC."

7. Approaches and new technology. Coders must know which approach the surgeon is using as well as what kind of technology. Ms. Kuley notes that codes need to be chosen based on the approach that the surgeon is using. New technologies also change the way a procedure in performed and this could result in a coding change.

Ms. Kuley also discussed two missed opportunities for coding that coders can keep in mind. These are:

•    A lot of providers don't bill for allografts and autografts because they think that payers do not consider them payable. While Medicare does deem these grafts as "zero value," it is key to note that not all payers deem them un-payable.
•    Also, CMS approved the addition of 10 spine codes to the ASC payable list earlier this year. However, CMS may not pay for add-on's to the codes. Thus, do your homework and bill for these codes if appropriate at your center.

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