Top 7 Challenges in Spine and Pain CodingJune 3, 2015
Lisa Rock, President
Jessica Edmiston, BS, CPC, CASCC, AHIMA Approved ICD-10 CM Trainer, Senior Vice President
Tamara Wagner, BS, CPC, Vice President
Alison Kuley, CPC, Spine Coder
www.nationalASCbilling.com
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Overview
• Tough coding issues
• Anatomy
• Documentation challenges
• LCDs and payor policies
• Medical necessity
• Applying NCCI edits
• Spine coding – implants
• Spine coding – approaches and new technology
• ICD-10
• Spine coding opportunities
• Discussion
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Tough Coding Issues:1 - Anatomy
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Anatomy
• Anatomy and code sets– Cervical
– Thoracic
– Lumbar
– Sacral
• Coders should know the full anatomy of the spine in order to interpret the operative note for :– Approach
– Proper level assignment
– Correct CPT and diagnosis assignment
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Transforaminal Epidural and Paravertebral Facet Joint Inject ions
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Anatomy of the Spine
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Anatomy of the Spine(cont.)
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Tough Coding Issues:2 - Documentation Challenges
Documentation Challenges:Pain
• Obtaining accurate and detailed documentation can be a challenge
• Discrepancies between procedure heading vs. actual description
• Inconsistencies within the operative report
• Missing information
• MD queries
• EHR cloning9
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Documentation Challenges:Spine
• Obtaining proper and accurate information could be the difference between billing one level or multiple levels
• Lumbar decompression– CPT 63047, CPT 63048
» Specific number of nerves decompressed need to be documented properly to ensure proper coding of additional levels
» Undocumented levels will reduce claim payment
Proper Documentation:Medial Branch Blocks
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Proper Documentation:Medial Branch Blocks
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Tough Coding Issues:3 – LCDs, NCDs and Payor Pol ic ies
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Local Coverage Determinations and Medical Necessity
• Policies are being updated more frequently
• Diagnosis driven
• Frequency of injections
• Progress of treatment
• Good communication needed between ASC and provider’s office
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Example: LCD vs. Payor Medical Pol icy
Procedure Note
Chief Complaint: bilateral neck and head pain Patient is a 71 year old female known to the clinic with the following diagnosis:
Pre-Operative Diagnosis: Facet joint pain, cervical/thoracic
Post-Operative Diagnosis: Facet joint pain, cervical/thoracic
Procedure: Medial branch block
Payor Medical Policy
Diagnosis to support medical necessity:
723.1 Cervicalgia
723.2 Cervicocranial syndrome
723.8 Other syndromes affecting cervical region
724.2 Lumbago
724.3 Sciatica
724.5 Backache, unspecified
MCR LCD ID L35336
Diagnosis to support medical necessity:
716.98* unspecified arthropathy involving other specified sites
721.0 cervical spondylosis w/o myelopathy
721.1 cervical spondylosis w/ myelopathy
721.2 thoracic spondylosis w/o myelopathy
721.3 lumbosacral spondylosis w/o myelopathy
721.41 spondylosis w/ myelopathy thoracic region
721.42 spondylosis w/ myelopathy lumbar region
723.8* other symptoms affecting cervical region
724.8* other symptoms referable to back
727.40 synovial cyst unspecified
733.82* nonunion of fracture
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Medicare LCD ID L35336(cont.)
• Medical necessity ICD-9 codes asterisk explanation:
• 716.98*
• Use for FACET ARTHROPATHY
• 723.8*
• Use for Occipital headache with CPT 64490 only
• 724.8*
• Use for FACET SYNDROME ONLY
• 733.82*
• Use for PSEUDOARTHROSIS ONLY
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Example: LCDs
• Therapeutic phase; procedures should be repeated as medically necessary; no more than four (4) injections of any type per region per patient per year.
• CPT 62310 – CPT 62311
ESI
• Maximum of five (5) facet joint injection sessions inclusive of MBBs, IA injections, facet cyst rupture and RF ablations may be performed per year in the cervical/thoracic spine and five (5) in the lumbar spine.
• Injections may be repeated if the first injection results in significant pain relief (>50%) for at least 3 months.
• CPT 64490 – CPT 64492
• CPT 64493 – CPT 64495
MBB
• Only when dual MBBs provide 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may facet joint denervation with RF medial branch neurotomy be considered.
• Repeat RFAs at same joint will only be considered medically necessary if the patient experienced 50% improvement of pain and specific ADLs documented for at least 6 months.
• CPT 64633 – CPT 64634
• CPT 64635 – CPT 64636
RFA
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Example: LCDs ESI
• In the first year, up to six (6) injection sessions per region may be performed; up to two (2) diagnostic and up to four (4) therapeutic
• In the following years, up to four (4) therapeutic injection session per region may be performed
Cahaba
•No more than three (3) epidurals may be performed in a 6-month period of time
•No more than six (6) ESI session (therapeutic and/or diagnostic) may be performed in a 12-month period of time regardless of the number of levels
Noridian
•Therapeutic, series of three (3) ESI may be given min. interval of two (2) weeks
•No more than two (2) levels on any given DOS (unilateral or bilateral)
•A series of three (3) ESI may be repeated at six (6) month intervals
First Coast
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Example: LCDs Medial Branch Blocks
• In the first year, up to six (6) injection session may be performed in the lumbar region: up to two (2) diagnostic and up to four (4) therapeutic
•Following years up to four (4) sessions may be performed
Cahaba
•A maximum of five (5) sessions per year in the cervical/thoracic and five (5) in the lumbar
Noridian
•Diagnostic phase should be limited to three (3) levels for each anatomical region
•No more than three (3) levels (unilateral or bilateral) per anatomic region on any given DOS - therapeutic and no less than 90 day intervals
First Coast
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Example: LCDs RFAs
•A maximum of two (2) sessions per nerve level per year may be performed in the lumbar region
Cahaba
•No more than two sessions will be reimbursed in any calendar year involving no more than four (4) joints per session (either two (2) bilateral levels or four (4) unilateral levels)
Noridian
•No more than two (2) treatments , right or left, within a 12 month (365 days) period of time
First Coast
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Trigger Point LCD:Cahaba
241098
Source Part B Policy Cahaba MAC - J10
Effective Date 03/01/2010
Publish Date January 1900
States Affected TN GA AL
Policy Number L30066
Subject Surgery: Trigger Point Injections
20552 Inj trigger point 1/2 muscles
20553 Inject trigger points 3/>
CPT/HCPCS Codes
ICD-9 Codes that Support Medical Necessity
For the following muscle groups use 720.1:
· Serratus anterior
· Serratus posterior
· Quadratus lumborum
· Longissimus thoracis
· Lower thoracic iliocostalis
· Upper and lower rectus abdominis
· Upper lumbar iliocostalis
· Multi fidus
· External oblique
· McBurney's point
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Trigger Point LCD:Cahaba(cont.)
720.1 SPINAL ENTHESOPATHY
723.9 UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK
For the following muscle groups use 723.9:· Trapezius (upper & lower)
· Sternocleido-mastoid (cervical & sternal)
· Masseter
· Temporalis
· Lateral pterygoid
· Splenii
· Posterior cervical
· Suboccipital
For the following muscle groups use 726.19:· Scaleni
· Subscapularis
· Levatorscapulae
· Brachialis
· Deltoid (anterior & posterior)
· Middle finger extensor
· Infraspinatus/supraspinatus
· First dorsal interosseous
· Pectoralis (major & minor)
· Supinator
· Latissimus dorsi
· Rhomboid
726.19 OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION
For the following muscle groups use 726.39:· Triceps
· Extensor carpi radialis
· Middle finger flexor
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Trigger Point LCD:Cahaba(cont.)
726.39 OTHER ENTHESOPATHY OF ELBOW REGION
726.5 ENTHESOPATHY OF HIP REGION
For the following muscle groups use 726.5:· Glutei, piriformis
· Adductor longus & brevis
For the following muscle groups use 726.71:· Soleus
· Gastroenemius
726.71 ACHILLES BURSITIS OR TENDINITIS
726.72 TIBIALIS TENDINITIS
For the following muscle groups use 726.72:· Tibialis anterior
For the following muscle groups use 726.79:· Peroneus longus & brevis
· Extensor digitorum & hallucis longus
· Third dorsal interosseous
726.79 OTHER ENTHESOPATHY OF ANKLE AND TARSUS
726.90 - 726.91 ENTHESOPATHY OF UNSPECIFIED SITE - EXOSTOSIS OF UNSPECIFIED SITE
For the following muscle groups use 726.90-726.91:· Rectus femoris
· Vastus intermedius
· Vastus medialis
· Vastus lateralis (anterior & posterior)
· Biceps femoral
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Trigger Point LCD:NGS
Source: Part B - NGS - MAC J6
Chapter:
Subject: Pain Management
Policy Number: L28529
Version: 2014-12-16 -
Jurisdiction
ILLINOIS
MINNESOTA
WISCONSIN
CPT/HCPCS Codes
Group 1 Paragraph: TRIGGER POINT INJECTIONS
Group 1 Codes:
20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2
MUSCLE(S)
20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR
MORE MUSCLE(S)
TRIGGER POINT INJECTIONS (CPT codes 20552 and 20553)
Group 1 Codes:
729.1MYALGIA AND MYOSITIS UNSPECIFIED
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Tough Coding Issues:4 – Medical Necessity
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Medical Necessity
• Payors are requiring documentation to support medical necessity
• Example of payor policy requirements to support medical necessity
• 3-6 months of conservative treatment
• Specific percentages of pain relief
• Prior physical therapy
• Medication therapy
• MRI findings
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Tough Coding Issues:5 – NCCI Edits
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Applying NCCI Edits
• What is your facility’s policy?
• NCCI or not?
• Know how your carriers code
• What about workers’ compensation?
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Tough Coding Issues:6 – Implants
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Spine Coding:Implants
• P-Stim / Auriculotherapy
– Miniaturized electro-stimulation device that operates on the principle of auricular (ear) nerve stimulation
• Vendors suggest using:
• CPT 64555 – Percutaneous implantation of neurostimulatorelectrode array; peripheral nerve (excludes sacral nerve)
• CPT L8680 – Implantable neurostimulator electrode, each
• Based on the documentation and payor policy, it would be appropriate to use:
– CPT 64999 – Unlisted procedure, nervous system
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Spine CodingImplants (cont.)
• November 2013 CPT Knowledgebase non-published response• CPT code 64999, Unlisted procedure, nervous system, may
be used to report the P-STIM procedure. When reporting an unlisted procedure, a report should be submitted with the claim. Pertinent information should include an adequate description of the nature and extent, and need for the procedure and time, effort, and equipment necessary to provide the service.
• Further, it would not be appropriate to report code 64555, Percutaneous implantations of neurostimulator electrode array; peripheral nerve (excludes sacral nerve), as this code is for implanted (directly into the body) nerve stimulator
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Tough Coding Issues:7 – Approaches & New Technology
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Spine Coding:Approach
• Knowing the approach that the surgeon is making is very important as many spine surgery CPT codes are chosen based upon the approach
– Anterior
– Posterior
– Lateral extracavitary
– Pre-sacral
• Examples of approach
– Lumbar interbody fusion
• Anterior – CPT 22558, posterior – CPT 22630 (just interbody), or CPT 22633 (interbody with posterior combination)
– Instrumentation
• Anterior – CPT 22845, posterior - CPT 22840 (non segmental), CPT 22842 (segmental)
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Spine Coding:Approach (cont.)
• Technology is changing how these procedures are being done
• Knowing how the procedure is being done will help you choose the appropriate CPT codes
• Incision types:
• Open approach
• Minimally invasive
• Endoscopic
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Spine Coding:Technology
• Technological advances have created new spine instrumentation being used to perform surgeries
• Older technology
– Interbody spacer made of PEEK (CPT 22851) or bone (CPT 20931)
– Anterior cervical plate and screws (CPT 22845)
• New technology
– Stand alone interbody spacers, PEEK spacer and screw all in one (CPT 22851), do not have separate plate or screws
» Would not bill CPT 22845 in addition to CPT 22851
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Spine Coding:Technology (cont.)
• Knowing what type of implant the physician is using is very important as many new implants are coded as “unlisted” because there is no appropriate way to report them as of yet
• Interspinous fusion devices
• Decompression devices
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ICD-10
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Example: I-9 to I-10 Crosswalk
722.0 – Displacement, Cervical Disc w/o myelopathy M5Ø.2Ø - Other cervical disc displacement, unspecified cervical region
M5Ø.21 – Other cervical disc displacement, high cervical region
M5Ø.22 – Other cervical disc displacement, mid-cervical region
M5Ø.23 – Other cervical disc displacement, cervicothoracic region
722.4 – Degeneration, Cervical Disc M5Ø.3Ø - Other cervical disc degeneration, unspecified cervical region
M5Ø.31 – Other cervical degeneration,high cervical region
M5Ø.32 – Other cervical degeneration, mid-cervical region
M5Ø.33 – Other cervical degeneration, cervicothoracic region
722.81 – Syndrome, Postlaminectomy, Cervical M96.1 - Postlaminectomy syndrome, not elsewhere classified
723.0 – Stenosis, Cervical Spine M48.Ø1 – Spinal stenosis occipito-altanto-axial region
M48.Ø2 - Spinal stenosis, cervical region
M48.Ø3 – Spinal stenosis cervicothoracic region
M99.2Ø – Subluxation stenosis neural canal of head region
M99.21 – Subluxation stenosis neural canal cervical region
M99.3Ø – Osseous stenosis of neural canal of head region
M99.31 - Osseous stenosis of neural canal of cervical region
M99.4Ø – Connective tissue stenosis of neural canal of head region
M99.41 - Connective tissue stenosis of neural canal of cervical region
M99.5Ø – Intervertebral disc stenosis of neural canal of head region
M99.51 - Intervertebral disc stenosis of neural canal of cervical region
M99.6Ø – Osseous subluxation stenosis intervertebral foramina of head region
M99.61 - Osseous subluxation stenosis intervertebral foramina of cervical region
M99.7Ø – Connective tissue stenosis intervertebral foramina of head region
M99.71 - Connective tissue stenosis intervertebral foramina of cervical region
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Spine Coding Opportunit ies
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Spine Coding:Opportunit ies
• Autograft (20936) and Allograft (20930)
– Medicare Reimbursement = $0
• Not inclusive to procedure, is not bundled
• Medicare deems this as a zero value
– Most physicians do not bill these procedure codes
– Some payors do pay on these codes
• Work comp (in some states)
• Auto (in some states)
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Spine Coding:Opportunit ies (cont.)
• CMS approved the addition of 10 spine codes to the ASC payable list:
22551 Neck spine fuse & remove bel c222554 Neck spine fusion22612 Lumbar spine fusion22614 Spine fusion extra segment63020 Neck spine disk surgery63030 Low back disk surgery63042 Laminotomy single lumbar63045 Removal of spinal lamina63047 Removal of spinal lamina63056 Decompress spinal cord
