How would you code ? 63047/63048/63030/22633

CoderinJax

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Hi! Need some help. Doc performed posterolateral arthrodesis (22633) and the below codes, but I don't agree that the records show enough to support.
I'm looking at a record and it states:

"hemilaminectomy was performed at L5 and a complete facetectomy at L5-S1 on the left side. The transversing S1 and exiting L5 nerve roots were identified. On the contralateral side, the undersurface of the lamina was undercut, elevate the ligamentum flavum off of the underlying dura decompressing the lateral recesses of the right side".

I don't feel this warrants billing 63047-59 or 63048-59, which the Physician did. Don't I need to see more in order to see either of these CPT codes? Appears to be more work than CPT 63030 since doing more than just "partial" facetectomy, but not enough to warrant the 63047 is my thought...

Thanks so much!
 

CHARLENA79

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Spine Surgery

22633 is a combined posterior interbody (22630) and posterolateral (22612) procedure at the same level. In your example L5-S1. According to the CMS 630xx series codes will no longer be reimbursed with the 2263x (interbody fusion codes) unless performed at a completely different level than the fusion. I.e., L3-L4. Hope this helps.
 

CoderinJax

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Hi! Thank you for the input, Charlena79!

I guess I'm curious as to if other coders think he's documented enough to even bill the additional codes, setting aside the NCCI policy manual rule..
Make sense?
 

sarab86

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Honestly, I bill 22630/22633 and 63047 together. It all depends on your diagnosis and what the intent for that decompression was. Can you support that he/she wasn't just preparing the disc space? If the intent for the decompression is to decompress the nerve root or cauda equina due to the stenosis then I would think you have enough to support 63047 with 59 to commercial carriers. Did the provider then go on to show separate work to prepare the disc space? If so, per CPT, these are separately payable. The only time I don't is for Medicare because they specifically set a rule for these code combinations. You would have to check with your carriers, but I was always taught that commercial carriers should follow CPT guidelines, unless they indicate otherwise. The exception would be Medicare replacement plans.

Hope this helps. Keep in mind who your coding compliance follows. We follow AANS.
 

CoderinJax

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Honestly, I bill 22630/22633 and 63047 together. It all depends on your diagnosis and what the intent for that decompression was. Can you support that he/she wasn't just preparing the disc space? If the intent for the decompression is to decompress the nerve root or cauda equina due to the stenosis then I would think you have enough to support 63047 with 59 to commercial carriers. Did the provider then go on to show separate work to prepare the disc space? If so, per CPT, these are separately payable. The only time I don't is for Medicare because they specifically set a rule for these code combinations. You would have to check with your carriers, but I was always taught that commercial carriers should follow CPT guidelines, unless they indicate otherwise. The exception would be Medicare replacement plans.

Hope this helps. Keep in mind who your coding compliance follows. We follow AANS.

Hi SaraB!
Thank you for the response! Even though commercial payers may follow CPT guidelines, if they also have policies stating they follow NCCI rules, I would bet the NCCI ruling will override the CPT in that case.
If adding the "59" to bypass the edits due to following CPT guidelines and they (Commercial carrier) state they follow NCCI edits/manuals, we'll lose that every time if the claims/medical records are audited, even if the documentation shows done for "other" than decompression. I think it's just a matter of an audit occurring (being "caught") that dictates whether they'll pay for it. Make sense?
(I'm specifically addressing 22630 or 22633 billed with 63047-59, 63042-59, or 63030-59)
 

amandamkcj

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CPT Assistant-October 2016/ Volume 26 Issue 10 now agrees with NCCI Edit stating:
Question: The procedures described in code 63047 was performed for decompression, which was documented in the operative note. In addition, the procedure described in code 22633 was also performed at the same interspace. How should this be reported?
Answer: Codes 63047 and 22633 cannot be reported for the same interspace. However, it is appropriate to report codes 63047 and 22633 if the two procedures are performed at different inerspaces. Modifier 59, Distinct Procedural Service, should be appended to indicate that these are two distinct procedure.

So based upon CPT Assistant they now agree with NCCI.

I hope this is helpful
 

CoderinJax

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Thanks Amandamkcj!

I'm comfortable in not having those codes submitted/paid together, my question was more along the lines of based on the OP report, do you think the Dr. even performed "enough" to justify the codes. Not so much are they payable. Does that make sense?
 
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