Alert:
HCFA Says CPT Code 49010 for Spinal Co-Surgery is Fraud
Published on Thu Jul 01, 1999
When a disk is herniated, the spine is curved and can be fixed either from the back or front. Neurosurgeons and orthopedists tend to favor the anterior approach because it makes the spine more stable. But typically they will require the services of a general surgeon to move organs out of the way and to open and close.
But what is now a relatively straightforward surgical procedure has become a serious coding dilemma for both the orthopedic/neurosurgeon and the general surgeon. Kathleen Mueller, RN, CPC, CCS-P, a physician reimbursement specialist who works with Allan L. Liefer, MD, FACS, in Chester, Ill., says she has fielded more questions on this particular problem than any other in the past two years.
Orthopedic and neurosurgeons will use CPT Code 22558 (Lumbar arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace) for the procedure.
So far so good. The question is: how does the general surgeon code his or her role during the procedure?
Many surgeons, often at the request of the orthopedic or neurosurgeon, use CPT code 49010 (Exploration, retroperitoneal area with or without biopsy(s)), where the physician may obtain sample tissue for separately reportable diagnostic testing.
However, when the general surgeon codes the procedure 49010, the claim is likely to be denied and, worse, if a Medicare claim is filed with the Health Care Financing Administration (HCFA), the use of 49010 will be considered unbundling because the relative value units (RVUs) for orthopedic and neurosurgical procedures already include exposure of the spine.
HCFA: Unbundling is Fraud
According to regulations on unbundling found in its National Correct Coding Initiative, which went into effect in July 1996, HCFA banned the the use of laparotomy (i.e. 49000 and 49010) or thoracotomy (32100) codes for the purpose of exposing the spine and considers the use of these codes in such procedures fraudulent.
So, how should the general surgeon code his role in the procedure?
The short answer is simple: general surgeons are required to list the same code (22258) as the orthopedic or neurosurgeon, and both physicians should also add CPT modifier -62, which signifies that both were co-surgeons during the procedure.
Cynthia Thompson, CPC, a senior consultant with Gates Moore & Company in Atlanta, also points to guidelines from the American Academy of Professional Coders recommending that both surgeons coordinate the filing of their claims and send their documentation in together, because carriers vary widely in terms of what kind of documentation they require.
This may [...]
