The reporting of orthopedic, spinal and pain management procedures continue to provide challenges for many ASCs regardless of whether the coder is a novice or a seasoned veteran. Below are five best practices to help ensure your facility captures reimbursement opportunities while adhering to coding guidelines.
1. Expertise in coding specialty procedures.
Simply because an ASC employs a certified coder does not denote the coder has a good working knowledge of the facility’s various specialties. For example, let’s consider newly added specialties. When a facility explores the possibility of adding new specialties, it assesses the costs to perform these procedures versus the reimbursement it receives once the procedure is performed. Often, the facility doesn’t consider the coder’s expertise or lack thereof in relation to these new procedures.
Would you expect your dentist to be able to perform an arthroscopic ACL reconstruction or your orthopedic surgeon to perform a four quadrant alveoloplasty for the preparation of dentures? Likewise, your ASC should not assume that coders, while certified, will be experts in orthopedic procedures if the only specialty they have been coding previously is ophthalmology. It is necessary for the facility to verify the coder’s knowledge and provide education prior to bringing these specialties on board.
2. Credible and current resources.
Your surgeons and OR staff have certain instrumentation preferences based on the type of procedure(s) being performed. Why would a facility expect anything less of its business office, particularly the coder? Provide the coder with current tools/resources from credible sources. Current coding books (CPT, ICD-9-CM, HCPCS), coding software, Medicare edits, local coverage determinations, AMA guidelines, individual specialty societies, and/or written carrier guidelines will assist the coder with accurately reporting procedures and maximizing reimbursement. Coders should avoid online “coding chat rooms” in which “opinion” is common and specific citations from Medicare and AMA are sparse.
The orthopedic specialty tends to generate an abundance of coding questions particularly in the areas of shoulders and spinal procedures. One recent challenge is spinal arthrodesis coding, not routinely performed in an ASC, as it pertains to crossing anatomic levels. Confusion arises when a multiple level arthrodesis is performed in which there is a crossover of anatomic regions.
For example: T10-L2 arthrodesis. Some coders and physicians attempt to code one primary code for the initial T level and one primary code for the initial L level with the add-on code reported for the additional levels. This is incorrect. Both the American Academy of Orthopaedic Surgeons (AAOS) and the North American Spine Society recommend reporting one primary arthrodesis, CPT 22612 (arthrodesis, posterior or posterolateral technique, single level, lumbar) and CPT 22614 for each additional level(s). The most extensive procedure is reported as primary with the additional levels reported with CPT 22614. Both CPT and CMS indicate that an arthrodesis at the lumbar level requires more work value than in the thoracic area.
3. Detailed clinical documentation.
Nothing says “cha-ching” like a detailed operative report. Deficient documentation practices may result in a lack in reimbursement opportunities, not to mention the additional time spent by both the coder and the physician with regards to querying or being queried for additional information. While facilities are encouraged to implement an acceptable query process, some coders erroneously undercode a procedure in order to get the claim billed. This practice is unacceptable.
Take, for example, an arthroscopic, knee, surgical, abrasion arthroplasty. There are specific guidelines regarding the documentation required to report CPT 29879 (arthroscopy, knee, surgical; abrasion arthroplasty or multiple drilling or microfracture). The AAOS states CPT 29879 is “appropriate when the procedure exposes bleeding subchondral bone.” The physician may describe debriding to bleeding bone or microfractures/drilling holes.
The surgeon’s operative statement, “I performed an arthroscopic abrasion arthroplasty” without describing the procedure does not warrant CPT 29879. If the surgeon states, “I performed a three compartmental arthroscopic abrasion arthroplasty,” without any additional description of the procedure, the coder will need to query to confirm reporting a three compartmental chondroplasty, CPT 29877 (arthroscopic, knee, surgical; debridement/ shaving of articular cartilage (chondroplasty)) x 1 versus a true arthroscopic abrasion arthroplasty, CPT 29879 x 3. Recall, when it is the only procedure performed in the knee, CPT 29877 is reported once regardless whether it is performed in one or three compartments ($900.78 x 1 approximate Medicare reimbursement). CPT 29879 is reported three times when performed in all three compartments ($842.28 + $842.28/2 + $842.28/2 approximate Medicare reimbursement).
4. Knowledge of Medicare vs. commercial reimbursement guidelines.
It is essential for the coder to be familiar with the facility’s various carrier contracts and reimbursement guidelines. The coder should be well versed in the utilization of Medicare edits and policies as well as the facility’s commercial carrier reporting policies and guidelines. Not all payors follow Medicare reporting policies allowing for more aggressive reporting. Facilities that follow Medicare across the board for all payors could be leaving money on the table. Regardless, the facility should establish a consistent protocol for the coder to follow.
5. Utilization of applicable modifiers.
In addition to understanding Medicare guidelines, the coder should be quite knowledgeable in regards to modifier usage. Mastering the Medicare edits can prove challenging. Coders tend to err on the side of caution when reviewing the edits or they don’t understand “when” modifiers should be appended to the CPT code to indicate a “separate” and “distinct” procedure that would otherwise be considered bundled. In this instance, the coder’s knowledge of the procedure(s) will assist in determining whether a modifier is applicable.
Medicare edits bundle CPT 63030 (laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically assisted approaches; 1 interspace, lumbar) into CPT 63047 (laminectomy, facetectomy and foraminotomy, single vertebral segment; lumbar) at this time but allows for a modifier if CPT 63030 is performed at a different level than CPT 63047 (i.e. CPT 63030 is performed at L5-S1 and CPT 63047 is performed at L4-L5).
Medicare edits bundle CPT Code 29823 (arthroscopy, shoulder extensive debridement) into CPT 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy) at this time but allow for a modifier if the debridement is performed separate and distinct from the distal claviculectomy. A coder’s unfamiliarity with the Medicare edits and its conventions might lead to the coder reporting only CPT 29824 since CPT 29823 is listed in the Medicare edits as an integral component despite operative documentation to the contrary. On the flip side, a coder’s comprehension of the detailed operative description coupled with an understanding of “when” to apply the -59 modifier will result in the reporting of both CPT 29824 and 29823-59 and ultimately capture additional reimbursement.(CPT 29823 = $1241.87 + CPT 29824 = $943.20/2 approximate Medicare reimbursement). It is important to reiterate that documentation must describe extensive debridement in significant areas/sites other than the area/site of the distal claviculectomy in order to report both codes.
Ms. Bentin (cristina@ccmpro.com) is a principal with Coding Compliance Management, a consulting company specializing in coding support, reimbursement and training for ASCs and specialty hospitals. Learn more about CCM at www.ccmpro.com.