Wiki Coding for a spine sugery

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GretchenC123

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I am auditing a surgeon's bill for a bilateral L3-4 and L4-5 microdiscectomy and he has used 63030-50, 63035-50, 63047, 63048, and 72100-26. When I do an NCCI check it tells me that he cannot bill for a 63030 with a 63047, but when I eliminate the 63030 it tells me that I have to have a code for the primary procedure. Any thoughts? Also, this is for a personal injury case so the surgeon could be billing and coding for duplicate procedures to get more money. The hospital only coded 63030 and 63035. Any input would be greatly appreciated.
 
If the surgery was performed for a lumbar disc herniation (microdiscectomy) it is 63030 for the first level and 63035 for each additional interspace. 63030 vs. 63047 are diagnosis driven procedures. If it's for stenosis it's 63047. You don't report both at the same level.
Also, why are they reporting an X-Ray?

 
Well, because this provider is trying to increase his payments. This is a lawsuit and the rules don't seem to apply to providers when there is a personal injury. So I guess he can only bill for a 63030 and 63035 bilateral. Is that correct?
 
If it is for disc herniation and going by words without an op note or other info, it is 63030 and 63035. There are many times they also call out stenosis in these cases but the intent and reason for surgery was the disc herniation (normally they have neuro symptoms, numbness, tingling, pain, disuse down the leg). It could just be that someone doesn't understand the rules/coding and tried to credit and bill the 63047 too because of that. This is a common spine coding error.

It also depends on if the payer uses NCCI edits/manual which is CMS not necessarily CPT. I have seen where Work Comp allows different things than McKesson edits or NCCI. So it depends.
 
Thank you for the info. I figure if the hospital billed it that way then so should the surgeon. This is a totally different situation than billing to a commercial or worker's comp carrier but it's good to have that info at hand.
 
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