Top 7 Challenges in Spine and Pain Coding

Top 7 Challenges in Spine and Pain Coding
June 3, 2015
Lisa Rock, President
Jessica Edmiston, BS, CPC, CASCC, AHIMA Approved ICD-10
CM Trainer, Senior Vice President
Tamara Wagner, BS, CPC, Vice President
Alison Kuley, CPC, Spine Coder
www.nationalASCbilling.com
O ve r v i e w
• Tough coding issues
• Anatomy
• Documentation challenges
• LCDs and payor policies
• Medical necessity
• Applying NCCI edits
• Spine coding – implants
• Spine coding – approaches and new technology
• ICD-10
• Spine coding opportunities
• Discussion
2
To u g h C o d i n g I s s u e s :
1 - Anatomy
3
Anatomy
• Anatomy and code sets
–
–
–
–
Cervical
Thoracic
Lumbar
Sacral
• Coders should know the full anatomy of the spine in order to
interpret the operative note for :
– Approach
– Proper level assignment
– Correct CPT and diagnosis assignment
4
Tr a n s f o r a m i n a l E p i d u r a l a n d
Pa r a v e r t e b r a l Fa c e t J o i n t I n j e c t i o n s
5
A n a t o my o f t h e S p i n e
6
A n a t o my o f t h e S p i n e
(cont.)
7
To u g h C o d i n g I s s u e s :
2 - Documentation Challenges
8
Documentation Challenges:
Pa i n
• Obtaining accurate and
detailed
documentation can be
a challenge
• Discrepancies between
procedure heading vs.
actual description
• Inconsistencies within
the operative report
• Missing information
• MD queries
• EHR cloning
9
Documentation Challenges:
Spine
• Obtaining proper and accurate information
could be the difference between billing one
level or multiple levels
• Lumbar decompression
– CPT 63047, CPT 63048
» Specific number of nerves decompressed need to be
documented properly to ensure proper coding of
additional levels
» Undocumented levels will reduce claim payment
10
Proper Documentation:
M e d i a l B ra n c h B l o c k s
11
Proper Documentation:
M e d i a l B ra n c h B l o c k s
12
To u g h C o d i n g I s s u e s :
3 – L C D s , N C D s a n d Pa y o r Po l i c i e s
13
L o c a l C ove ra g e D e t e r m i n a t i o n s
and Medical Necessity
• Policies are being updated more frequently
• Diagnosis driven
• Frequency of injections
• Progress of treatment
• Good communication needed between ASC and provider’s
office
14
E x a m p l e : LC D v s . Payo r M e d i c a l
Po l i c y
Procedure Note
Chief Complaint: bilateral neck and head pain Patient is a 71 year old female known to the clinic with the following
diagnosis:
Pre-Operative Diagnosis: Facet joint pain, cervical/thoracic
Post-Operative Diagnosis: Facet joint pain, cervical/thoracic
Procedure: Medial branch block
MCR LCD ID L35336
Diagnosis to support medical necessity:
716.98*
unspecified arthropathy involving other
specified sites
721.0
cervical spondylosis w/o myelopathy
721.1
cervical spondylosis w/ myelopathy
721.2
thoracic spondylosis w/o myelopathy
721.3
lumbosacral spondylosis w/o myelopathy
721.41
spondylosis w/ myelopathy thoracic region
721.42
spondylosis w/ myelopathy lumbar region
723.8*
other symptoms affecting cervical region
724.8*
other symptoms referable to back
727.40
synovial cyst unspecified
733.82*
nonunion of fracture
Payor Medical Policy
Diagnosis to support medical necessity:
723.1
Cervicalgia
723.2
Cervicocranial syndrome
723.8
Other syndromes affecting cervical region
724.2
Lumbago
724.3
Sciatica
724.5
Backache, unspecified
15
M e d i c a r e LC D I D L 3 5 3 3 6
(cont.)
• Medical necessity ICD-9 codes asterisk explanation:
• 716.98*
• Use for FACET ARTHROPATHY
• 723.8*
• Use for Occipital headache with CPT 64490 only
• 724.8*
• Use for FACET SYNDROME ONLY
• 733.82*
• Use for PSEUDOARTHROSIS ONLY
16
E x a m p l e : LC D s
• Therapeutic phase;
procedures should be
repeated as medically
necessary; no more than four
(4) injections of any type per
region per patient per year.
• CPT 62310 – CPT 62311
ESI
• Maximum of five (5) facet joint
injection sessions inclusive of
MBBs, IA injections, facet cyst
rupture and RF ablations may be
performed per year in the
cervical/thoracic spine and five
(5) in the lumbar spine.
• Injections may be repeated if
the first injection results in
significant pain relief (>50%) for
at least 3 months.
• CPT 64490 – CPT 64492
• CPT 64493 – CPT 64495
MBB
• Only when dual MBBs provide 80%
relief of the primary or index pain
and duration of relief is consistent
with the agent employed may facet
joint denervation with RF medial
branch neurotomy be considered.
• Repeat RFAs at same joint will only
be considered medically necessary
if the patient experienced 50%
improvement of pain and specific
ADLs documented for at least 6
months.
• CPT 64633 – CPT 64634
• CPT 64635 – CPT 64636
RFA
17
E x a m p l e : LC D s E S I
• In the first year, up to six (6)
injection sessions per region
may be performed; up to
two (2) diagnostic and up to
four (4) therapeutic
• In the following years, up to
four (4) therapeutic
injection session per region
may be performed
• No more than three (3)
epidurals may be performed
in a 6-month period of time
• No more than six (6) ESI
session (therapeutic and/or
diagnostic) may be
performed in a 12-month
period of time regardless of
the number of levels
• Therapeutic, series of three
(3) ESI may be given min.
interval of two (2) weeks
• No more than two (2) levels
on any given DOS (unilateral
or bilateral)
• A series of three (3) ESI may
be repeated at six (6) month
intervals
Cahaba
Noridian
First Coast
18
E x a m p l e : LC D s M e d i a l B ra n c h
Blocks
• In the first year, up to six (6)
injection session may be
performed in the lumbar
region: up to two (2)
diagnostic and up to four (4)
therapeutic
• Following years up to four
(4) sessions may be
performed
• A maximum of five (5)
sessions per year in the
cervical/thoracic and five (5)
in the lumbar
• Diagnostic phase should be
limited to three (3) levels for
each anatomical region
• No more than three (3)
levels (unilateral or bilateral)
per anatomic region on any
given DOS - therapeutic and
no less than 90 day intervals
Cahaba
Noridian
First Coast
19
E x a m p l e : LC D s R FA s
• A maximum of two (2)
sessions per nerve level per
year may be performed in
the lumbar region
• No more than two sessions
will be reimbursed in any
calendar year involving no
more than four (4) joints per
session (either two (2)
bilateral levels or four (4)
unilateral levels)
• No more than two (2)
treatments , right or left,
within a 12 month (365
days) period of time
Cahaba
Noridian
First Coast
20
Tr i g g e r Po i n t LC D :
Cahaba
241098
Source
Part B Policy Cahaba MAC - J10
Effective Date
03/01/2010
Publish Date
January 1900
States Affected
TN GA AL
Policy Number
L30066
Subject
Surgery: Trigger Point Injections
CPT/HCPCS Codes
20552
Inj trigger point 1/2 muscles
20553
Inject trigger points 3/>
ICD-9 Codes that Support Medical Necessity
For the following muscle groups use 720.1:
· Serratus anterior
· Serratus posterior
· Quadratus lumborum
· Longissimus thoracis
· Lower thoracic iliocostalis
· Upper and lower rectus abdominis
· Upper lumbar iliocostalis
· Multi fidus
· External oblique
· McBurney's point
21
Tr i g g e r Po i n t LC D :
Cahaba(cont.)
720.1
SPINAL ENTHESOPATHY
For the following muscle groups use 723.9:
· Trapezius (upper & lower)
·
·
·
·
·
·
·
Sternocleido-mastoid (cervical & sternal)
Masseter
Temporalis
Lateral pterygoid
Splenii
Posterior cervical
Suboccipital
723.9
UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK
For the following muscle groups use 726.19:
· Scaleni
·
·
·
·
·
·
·
·
·
·
·
Subscapularis
Levatorscapulae
Brachialis
Deltoid (anterior & posterior)
Middle finger extensor
Infraspinatus/supraspinatus
First dorsal interosseous
Pectoralis (major & minor)
Supinator
Latissimus dorsi
Rhomboid
726.19
OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION
For the following muscle groups use 726.39:
· Triceps
· Extensor carpi radialis
· Middle finger flexor
22
Tr i g g e r Po i n t LC D :
Cahaba(cont.)
726.39
OTHER ENTHESOPATHY OF ELBOW REGION
For the following muscle groups use 726.5:
· Glutei, piriformis
· Adductor longus & brevis
726.5
ENTHESOPATHY OF HIP REGION
For the following muscle groups use 726.71:
· Soleus
· Gastroenemius
726.71
ACHILLES BURSITIS OR TENDINITIS
For the following muscle groups use 726.72:
· Tibialis anterior
726.72
TIBIALIS TENDINITIS
For the following muscle groups use 726.79:
· Peroneus longus & brevis
· Extensor digitorum & hallucis longus
· Third dorsal interosseous
726.79
OTHER ENTHESOPATHY OF ANKLE AND TARSUS
For the following muscle groups use 726.90-726.91:
· Rectus femoris
· Vastus intermedius
· Vastus medialis
· Vastus lateralis (anterior & posterior)
· Biceps femoral
726.90 - 726.91
ENTHESOPATHY OF UNSPECIFIED SITE - EXOSTOSIS OF UNSPECIFIED SITE
23
Tr i g g e r Po i n t LC D :
NGS
Source: Part B - NGS - MAC J6
Chapter:
Subject: Pain Management
Policy Number: L28529
Version: 2014-12-16 -
Jurisdiction
ILLINOIS
MINNESOTA
WISCONSIN
CPT/HCPCS Codes
Group 1 Paragraph: TRIGGER POINT INJECTIONS
Group 1 Codes:
20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2
MUSCLE(S)
20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR
MORE MUSCLE(S)
TRIGGER POINT INJECTIONS (CPT codes 20552 and 20553)
Group 1 Codes:
729.1MYALGIA AND MYOSITIS UNSPECIFIED
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To u g h C o d i n g I s s u e s :
4 – Medical Necessity
25
Medical Necessity
• Payors are requiring documentation to support
medical necessity
• Example of payor policy requirements to
support medical necessity
•
•
•
•
•
3-6 months of conservative treatment
Specific percentages of pain relief
Prior physical therapy
Medication therapy
MRI findings
26
To u g h C o d i n g I s s u e s :
5 – NCCI Edits
27
Applying NCCI Edits
•
•
•
•
What is your facility’s policy?
NCCI or not?
Know how your carriers code
What about workers’ compensation?
28
To u g h C o d i n g I s s u e s :
6 – Implants
29
Spine Coding:
Implants
• P-Stim / Auriculotherapy
– Miniaturized electro-stimulation device that operates on
the principle of auricular (ear) nerve stimulation
• Vendors suggest using:
• CPT 64555 – Percutaneous implantation of neurostimulator
electrode array; peripheral nerve (excludes sacral nerve)
• CPT L8680 – Implantable neurostimulator electrode, each
• Based on the documentation and payor policy, it
would be appropriate to use:
– CPT 64999 – Unlisted procedure, nervous system
30
Spine Coding
Implants (cont.)
• November 2013 CPT Knowledgebase non-published
response
• CPT code 64999, Unlisted procedure, nervous system, may
be used to report the P-STIM procedure. When reporting an
unlisted procedure, a report should be submitted with the
claim. Pertinent information should include an adequate
description of the nature and extent, and need for the
procedure and time, effort, and equipment necessary to
provide the service.
• Further, it would not be appropriate to report code 64555,
Percutaneous implantations of neurostimulator electrode
array; peripheral nerve (excludes sacral nerve), as this code
is for implanted (directly into the body) nerve stimulator
31
To u g h C o d i n g I s s u e s :
7 – A p p r o a c h e s & N e w Te c h n o l o g y
32
Spine Coding:
Approach
• Knowing the approach that the surgeon is making is very important as
many spine surgery CPT codes are chosen based upon the approach
– Anterior
– Posterior
– Lateral extracavitary
– Pre-sacral
• Examples of approach
– Lumbar interbody fusion
• Anterior – CPT 22558, posterior – CPT 22630 (just interbody), or CPT 22633
(interbody with posterior combination)
– Instrumentation
• Anterior – CPT 22845, posterior - CPT 22840 (non segmental), CPT 22842
(segmental)
33
Spine Coding:
Approach (cont.)
• Technology is changing how these procedures are
being done
• Knowing how the procedure is being done will help
you choose the appropriate CPT codes
• Incision types:
•
•
•
Open approach
Minimally invasive
Endoscopic
34
Spine Coding:
Te c h n o l o g y
• Technological advances have created new spine
instrumentation being used to perform surgeries
•
Older technology
– Interbody spacer made of PEEK (CPT 22851) or bone
(CPT 20931)
– Anterior cervical plate and screws (CPT 22845)
•
New technology
– Stand alone interbody spacers, PEEK spacer and screw all in
one (CPT 22851), do not have separate plate or screws
» Would not bill CPT 22845 in addition to CPT 22851
35
Spine Coding:
Te c h n o l o g y ( c o n t . )
• Knowing what type of implant the physician is using
is very important as many new implants are coded
as “unlisted” because there is no appropriate way to
report them as of yet
•
•
Interspinous fusion devices
Decompression devices
36
ICD-10
37
Example:
I- 9 t o I - 1 0 C r o s s wa l k
722.0 – Displacement, Cervical Disc w/o myelopathy
M5Ø.2Ø - Other cervical disc displacement, unspecified cervical region
M5Ø.21 – Other cervical disc displacement, high cervical region
M5Ø.22 – Other cervical disc displacement, mid-cervical region
M5Ø.23 – Other cervical disc displacement, cervicothoracic region
722.4 – Degeneration, Cervical Disc
M5Ø.3Ø - Other cervical disc degeneration, unspecified cervical region
M5Ø.31 – Other cervical degeneration,high cervical region
M5Ø.32 – Other cervical degeneration, mid-cervical region
M5Ø.33 – Other cervical degeneration, cervicothoracic region
722.81 – Syndrome, Postlaminectomy, Cervical
723.0 – Stenosis, Cervical Spine
M96.1 - Postlaminectomy syndrome, not elsewhere classified
M48.Ø1 – Spinal stenosis occipito-altanto-axial region
M48.Ø2 - Spinal stenosis, cervical region
M48.Ø3 – Spinal stenosis cervicothoracic region
M99.2Ø – Subluxation stenosis neural canal of head region
M99.21 – Subluxation stenosis neural canal cervical region
M99.3Ø – Osseous stenosis of neural canal of head region
M99.31 - Osseous stenosis of neural canal of cervical region
M99.4Ø – Connective tissue stenosis of neural canal of head region
M99.41 - Connective tissue stenosis of neural canal of cervical region
M99.5Ø – Intervertebral disc stenosis of neural canal of head region
M99.51 - Intervertebral disc stenosis of neural canal of cervical region
M99.6Ø – Osseous subluxation stenosis intervertebral foramina of head region
M99.61 - Osseous subluxation stenosis intervertebral foramina of cervical region
M99.7Ø – Connective tissue stenosis intervertebral foramina of head region
M99.71 - Connective tissue stenosis intervertebral foramina of cervical region
38
Spine Coding Opportunities
39
Spine Coding:
Opportunities
• Autograft (20936) and Allograft (20930)
– Medicare Reimbursement = $0
• Not inclusive to procedure, is not bundled
• Medicare deems this as a zero value
– Most physicians do not bill these procedure codes
– Some payors do pay on these codes
• Work comp (in some states)
• Auto (in some states)
40
Spine Coding:
Opportunities (cont.)
• CMS approved the addition of 10 spine codes to the ASC payable
list:
22551 Neck spine fuse & remove bel c2
22554 Neck spine fusion
22612 Lumbar spine fusion
22614 Spine fusion extra segment
63020 Neck spine disk surgery
63030 Low back disk surgery
63042 Laminotomy single lumbar
63045 Removal of spinal lamina
63047 Removal of spinal lamina
63056 Decompress spinal cord
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Discussion
[email protected]
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