Orthopedic Coding Alert

Fight those spine bundle denials whenever possible

You may have won out over edits that made posterior lumbar interbody fusion (PLIF) a component of posterolateral fusion. But you could still be receiving denials when you report PLIF with other services.

The problem: Many carriers won't allow you to bill 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar) in addition to PLIF code 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar). The carriers believe that laminectomy is always part of PLIF because surgeons often use laminectomy to clear a space for fusion.

-Most carriers, including Medicare, simply don't want to pay for this procedure, 63047, when done along with the interbody fusion, 22630,- says Tom Herron, a spine-coding specialist in Indianapolis. -We see far more denials than we should.-

However, you should be able to separately bill 63047 when your surgeon does more than just clear a space for the PLIF. The January 2001 CPT Assistant says that you can report 63045-63048 -when in addition to removing the disk and preparing the vertebral endplate, the surgeon removes posterior osteophytes and decompresses the spinal cord or nerve root(s), which requires work in excess of that normally performed when doing a posterior lumbar interbody fusion.-

Learn From 1 Coder's Achievement

Success story: Tulsa, Okla., coding and billing consultant Katherine Phelan took one year's worth of PLIFs performed by a five-doctor practice and reviewed all of the billing, documentation and reimbursement. She appealed all of the denials for 63045-63048 that had documentation substantiating that the laminectomy was for decompression. As a result, the practice received $300,000.

-This money had already been written off as bundled,- Phelan says. The lesson: It's always worth reviewing and appealing unpaid claims.

Note: Because National Correct Coding Initiative edits bundle 63047 into 22630, you should attach modifier 59 (Distinct procedural service) to 63047 where appropriate, Phelan says. 

Document everything: Make it clear to the physicians that if they want to collect the maximum reimbursement allowable, they must document the procedure clearly. If the physician does a laminectomy as a separate procedure from the PLIF, the op report needs to state that he did the laminectomy specifically to -decompress the spinal canal and/or any nerve roots,- not just to prepare the spine for fusion. Along with the documentation of the procedure, remember to include an ICD-9 code that justifies both procedures.

Educate your physician: The surgeon may know all the steps he performed, but the claims processor can't read between the lines, Phelan says. You-ll risk denials if the doctor doesn't write -in black and white- why the extra decompression was necessary, she says.

Facing a wave of denials, Herron talked to his physicians and even attended some surgeries to see the process for himself. The physician should include three key elements in his dictation:

1. what he decompressed

2. what he did in detail, including which laminae were removed, whether or not he performed foraminotomy and/or facetectomy, and which nerve roots the surgeon decompressed

3. whether the decompression was successful.

Physicians at Herron's practice have become diligent about including these three elements in their documentation.

Warning: Even with modifier 59 and complete documentation, some payers still won't cover 63047 with 22630, says Denae Merrill, a coder with Covenant MSO in Saginaw, Mich., and secretary of the MBS chapter of the American Academy of Professional Coders.
 
In those cases, Merrill will attach the op note and highlight the portions that show the decompression and the arthrodesis in separate colors.

Then she attaches copies of the pages from her CPT book that indicate 22630 is for -other than decompression- and 63047 is for decompression. You can also attach the CPT Assistant article from January 2001 or other direction from one of the specialty societies.

Note: If you-ve recently scored a coding success that you-d like to share with our readers, please contact our editor, Torrey Kim, at (919) 924-2833 or by e-mail at torrey@medville.com.