Part B Insider (Multispecialty) Coding Alert

Published on Mon Nov 20, 2006 PDF

Don't take spine decompression denials lying down

You may have won out over edits that made posterior lumbar interbody fusion (PLIF) code 22630 a component of posterolateral fusion code 22612. (See PBI, Vol. 7, No. 29.) But you still could be receiving denials when you bill 22630 with another code.

The problem: Many carriers won't allow you to bill for laminectomy code 63047 in addition to PLIF code 22630, say coders. 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, coding specialist with Indianapolis Neurosurgical Group. -We see far more denials than we should.-

However, you should be able to bill for 63047 separately when your doctor 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.-

Success story: Tulsa, OK coding and billing consultant Katherine Phelan took one year's worth of PLIFs performed by a five-doctor neurosurgery 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 notes. The lesson: It's always worth reviewing and appealing unpaid claims.

Note: Because Correct Coding Initiative edits bundled 63047 into 22630, you should attach a 59 modifier to 63047 where appropriate, Phelan notes.

Document everything: -I have made it clear to my physicians that if they want me to code so that they can be paid, then they need to document the procedure clearly,- says Jennifer Schmutz, health information coder with Neurosurgical Associates in Salt Lake City, UT. If the physician does a laminectomy as a separate procedure from the PLIF, the op report needs to state that he or she did the laminectomy specifically to -decompress the spinal canal as well as any nerve roots,- not just to prepare the spine for fusion, she says.

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

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

1) what they compressed;
2) what they did in detail; and
3) whether they accomplished decompression.

The doctors at Indianapolis Neurosurgical have become diligent about including these three elements in their documentation, says Herron.

Warning: Even with the 59 modifier and complete documentation, some payors still won't cover 63047 with 22630, notes Denae Merrill, a coder with Covenant MSO in Saginaw, MI 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. She also attaches an article from the American Academy of Neurological Surgeons that references the CPT Assistant article.