Neurosurgery Coding Alert

Cervical spinal fusion lands at the top of costliest medical necessity mistakes.

You know that medical necessity, correct coding, and sufficient documentation are just some of the details you must pay attention to as you submit claims in your neurosurgery office. However, no matter how careful you are, errors can still crop up. In fact, a top error in neurosurgery clocked in with medical necessity regarding cervical spinal fusion with projected improper payments of over $85 million, per CMS’ most recent CERT report.

Background: CMS issued the “2020 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 21 as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims and covers the causes of the improperly paid charges. Overall, the government found a 6.3 percent improper payment rate (8.1 percent for Part B) among claims submitted during the 12-month period from July 1, 2018 through June 30, 2019.

Medical Necessity Ranks as Most Costly Error

Several neurosurgery-related procedures and diagnoses contributed to medical necessity errors, the most costly type of error for this specialty.

Cervical spinal fusion came in at over $85 million in projected improper payments with a 12.7 percent improper payment rate.

Spinal fusion, except cervical, came in at over $78 million in projected improper payments with a 5.2 percent improper payment rate.

Finally, degenerative nervous system disorders had over $48 million in projected improper payments at a 5.7 percent improper payment rate.

“There were several striking findings in the 2020 CERT report,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “First, three categories of spinal fusions and a fourth category of neurodegenerative disorders comprised four of the top twenty service types identified with the highest proportion of improper payments. However, the identified reasons for improper payments varied among the service types. For example, improper payments for non-cervical fusions were comprised of nearly equal portions of insufficient documentation and medical necessity, with a minority 10 percent attributable to coding errors.”

For anterior-posterior fusions, about 80 percent of improper payments were for insufficient documentation and the remainder attributed to improper coding, Przybylski says. In contrast, 90 percent of improper payments for cervical fusion were based on medical necessity, with a minority attributable to insufficient documentation. While proper documentation is always important, the report highlights the importance of demonstrating medical necessity for performing cervical fusions.”

Spot These Incorrect Coding Errors

Neurosurgery also saw some errors due to incorrect coding.

Intracranial hemorrhage or cerebral infarction had over $26 million projected improper payments at a 1.8 percent improper payment rate.

Combined anterior/posterior spinal fusion had over $25 million projected improper payments at a 1.4 percent improper payment rate.

Observe Multiple Downcoding Mistakes

Downcoding also contributed to numerous neurosurgery coding errors.

Combined anterior/posterior spinal fusion had over $17 million projected improper payments with a 1 percent improper payment rate.

Intracranial hemorrhage or cerebral infarction had over $25 million in projected improper payments with a 1.7 percent improper payment rate.

Craniotomy and endovascular intracranial procedures had over $8 million in projected improper payments.

Finally, extracranial procedures had over $8 million in projected improper payments with a 2.8 percent improper payment rate.

Advanced Imaging Racks Up Millions in Projected Improper Payments

Advanced imaging also showed up on “Table G1: Improper Payment Rates by Service Type: Part B.”

Advanced imaging, MRI/MRA, of the brain, head, neck had over $30 million in projected improper payments at a 10.4 percent improper payment rate.

Advanced imaging, CAT/CT/CTA, of the brain/head/neck had over $26 million in projected improper payments at a 6.6 percent improper payment rate.

See Which E/M Codes Featured the Most Errors

CMS breaks down which evaluation and management (E/M) codes had the most incorrect coding errors among all Part B providers, with the following among the biggest offenders:

• Established patient office visits. The outpatient established E/M codes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …) represented $400.9 million in projected improper payments.
• Initial hospital visits. In the initial hospital visit E/M category (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient …), Medicare made $359.5 million in projected Part B improper payments.
• Subsequent hospital visits. The codes for subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient …) represented $261.6 million in improper payments.
• New patient office visits. Coming in fourth on the list, the new patient E/M codes (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient …) were responsible for $260.6 million in improper payments.
• Hospital visit – critical care. The fifth code series with incorrect coding error involved critical care visits (99291- +99292, Critical care, evaluation and management of the critically ill or critically injured patient …), logging $146.1 million in projected improper payments.

As most practices are aware, it’s critical to ensure that you’re reporting your E/M services accurately. Particularly in light of the reimbursement losses that many physicians are facing due to the pandemic, you want to hang on to as much of your income as you can, and correct coding is the best way to do that.

Resource: To read the full CERT document, visit www.cms.gov/restricted-access-vbdlvcertreportsdl/2020-medicare-fee-service-supplemental-improper-payment-data.