Here are five coding and documentation tips for spine surgeons to optimize reimbursements.
1. Obtain correct physician documentation. Obtain full documentation for spine procedures, operative notes, anesthesia and medication list before you begin coding.
"You have to make sure all is in order before starting to code," says National Medical Billing Service's Senior Vice President, Coding Angela Talton. "There are several challenges, especially when we have more than one procedure. We have to ensure we are assigning the level of specificity for any spine procedure and the correct modifiers. Claims can be denied because modifiers are not affixed to the second tertiary procedure. That can be very costly and time consuming from a revenue cycle point of view."
This documentation will become even more specific after the transition to ICD-10 in October 2014.
"Physician education is going to be critical during the upcoming days, weeks and months leading up to ICD-10 conversion," says Ms. Talton. "Physicians need to be made very aware of how they are noting procedures. They need to be very specific and aware of how they are wording their reports to avoid ambiguity in their operative findings. I suspect there will be physician queries when the operative notes are not clear, so if there is an opportunity for physician education, start now and continue through implementation. Otherwise, there is a huge drop in reimbursement because of that."
2. Avoid using unlisted codes. Whenever ASCs use an unlisted code they are challenged for reimbursement because the unlisted code signifies "experimental" to the payor. Payors often don't want to reimburse for "experimental" treatments in the outpatient or inpatient setting.
"When you are doing procedures with unlisted codes, you have to make sure the carrier covers them," says Barbara Cataletto, founder and CEO of Business Dynamics. "Most carriers clearly identify non-covered items on their websites. Trying to sneak the procedure in the back door and then fighting for reimbursement afterwards isn't the way to go because then the patient is charged for the service."
3. Watch for payor coverage updates closely. Surgeons and spine practices have begun to receive coverage denials for procedures and practices that were previously covered by insurance companies. One big example has been biomaterials, such as the new bio grafting materials which are now classified as non-covered services, even though they have been recognized and covered in the past.
"It's not the entire procedure, it's just the biomaterials that were being denied in most cases," says Ms. Cataletto. "They were covered in applications for several years, but now they are considered experimental, therefore, not covered. This doesn't make sense because bone marrow aspirates had minimal physician reimbursements — $100 or so — now if you include it in your surgical case, insurance companies won't approve reimbursement for the entire case. This is unusual and I haven't seen anything like this in the past."
Keep a close eye on the insurance company website for policy updates and make sure your office staff notifies you of any changes in claim denials.
4. Argue for medical necessity. Payors are increasingly denying spinal procedures based on "medical necessity," or lack thereof. Insurance companies claim surgery isn't medically necessary for a variety of reasons, including in situations where approval was readily granted in the past.
"There have been class action settlements in recent years — approved at various times between 2003 and 2006 — that have penalized insurers for unethical and unfair business practices," says Sean Weiss, vice president and chief compliance officer for DoctorsManagement. "The Second Circuit Court of Appeals decided numerous cases where medical necessity is mentioned. However, only one case actually described what the term means in absence of a definition in an insurance plan's documentation, saying 'unless the contrary is specified, the term medical necessity must refer to what is medically necessary for a particular patient, and hence entails an individual assessment rather than general determination of what works in the ordinary case."
Insurance companies such as Aetna, Cigna and Humana have entered into settlement agreements with more than 900,000 physicians and state and county medical societies in a class action lawsuit. However, settlements have expiration dates and vary by payor, so at some point the payors will not be bound by the definition of medical necessity within the settlements.
"I encourage physicians to play an active role in writing the appeal letters for claims that have been denied due to medical necessity, as you do not want to leave that to the discretion of a non-clinician," says Mr. Weiss. "However, for the practices that still cannot get the physician to write the appeal letter of medical necessity, there is simple language practice staff can use."
5. Re-submit or appeal denied claims. Don't leave money on the table by tossing denied insurance claims. If the claim was denied for a coding error, fix the mistake and resubmit; if it was denied for another reason, appeal the payor's decision as far as possible.
"Insurance companies are making up bogus algorithms to deny surgery, and I don't know where they are coming from," says Hooman Melamed, MD, an orthopedic spine surgeon with DISC Sports & Spine Center in Marina Del Rey, Calif. "They aren't paying attention to the clinical notes and they are saying surgery isn't indicated, when clearly the findings are there. They are doing it hoping the patient and surgeon will give up and the surgery won't be performed. I've had denials for fusion in scoliosis and other deformity procedures where patients failed conservative therapy and they are still telling me the patient isn't a surgical candidate."
It's important to fight for coverage from the preauthorization stage, but just receiving the go-ahead for surgery doesn't mean your work is over.
"Keep in mind, pre-certification approval is in no way a guarantee of payment once the services have been rendered and a claim has been submitted for reimbursement," says Mr. Weiss. "That is why it becomes critical for them to have staff that is highly educated and trained in the 'business of medicine' so they can have the requisite skills necessary to secure the reimbursements the presence has emitted you to."
More Articles on Spine Surgeons:
Outlook for Spinal Non-Fusion Technology Trends: Q&A With Joe Ross of LDR
5 Factors Influencing Spine Fellows Turn Towards Academia
5 Spine Surgeons on Enduring EMR Adoption
1. Obtain correct physician documentation. Obtain full documentation for spine procedures, operative notes, anesthesia and medication list before you begin coding.
"You have to make sure all is in order before starting to code," says National Medical Billing Service's Senior Vice President, Coding Angela Talton. "There are several challenges, especially when we have more than one procedure. We have to ensure we are assigning the level of specificity for any spine procedure and the correct modifiers. Claims can be denied because modifiers are not affixed to the second tertiary procedure. That can be very costly and time consuming from a revenue cycle point of view."
This documentation will become even more specific after the transition to ICD-10 in October 2014.
"Physician education is going to be critical during the upcoming days, weeks and months leading up to ICD-10 conversion," says Ms. Talton. "Physicians need to be made very aware of how they are noting procedures. They need to be very specific and aware of how they are wording their reports to avoid ambiguity in their operative findings. I suspect there will be physician queries when the operative notes are not clear, so if there is an opportunity for physician education, start now and continue through implementation. Otherwise, there is a huge drop in reimbursement because of that."
2. Avoid using unlisted codes. Whenever ASCs use an unlisted code they are challenged for reimbursement because the unlisted code signifies "experimental" to the payor. Payors often don't want to reimburse for "experimental" treatments in the outpatient or inpatient setting."When you are doing procedures with unlisted codes, you have to make sure the carrier covers them," says Barbara Cataletto, founder and CEO of Business Dynamics. "Most carriers clearly identify non-covered items on their websites. Trying to sneak the procedure in the back door and then fighting for reimbursement afterwards isn't the way to go because then the patient is charged for the service."
3. Watch for payor coverage updates closely. Surgeons and spine practices have begun to receive coverage denials for procedures and practices that were previously covered by insurance companies. One big example has been biomaterials, such as the new bio grafting materials which are now classified as non-covered services, even though they have been recognized and covered in the past.
"It's not the entire procedure, it's just the biomaterials that were being denied in most cases," says Ms. Cataletto. "They were covered in applications for several years, but now they are considered experimental, therefore, not covered. This doesn't make sense because bone marrow aspirates had minimal physician reimbursements — $100 or so — now if you include it in your surgical case, insurance companies won't approve reimbursement for the entire case. This is unusual and I haven't seen anything like this in the past."
Keep a close eye on the insurance company website for policy updates and make sure your office staff notifies you of any changes in claim denials.
4. Argue for medical necessity. Payors are increasingly denying spinal procedures based on "medical necessity," or lack thereof. Insurance companies claim surgery isn't medically necessary for a variety of reasons, including in situations where approval was readily granted in the past.
"There have been class action settlements in recent years — approved at various times between 2003 and 2006 — that have penalized insurers for unethical and unfair business practices," says Sean Weiss, vice president and chief compliance officer for DoctorsManagement. "The Second Circuit Court of Appeals decided numerous cases where medical necessity is mentioned. However, only one case actually described what the term means in absence of a definition in an insurance plan's documentation, saying 'unless the contrary is specified, the term medical necessity must refer to what is medically necessary for a particular patient, and hence entails an individual assessment rather than general determination of what works in the ordinary case."
Insurance companies such as Aetna, Cigna and Humana have entered into settlement agreements with more than 900,000 physicians and state and county medical societies in a class action lawsuit. However, settlements have expiration dates and vary by payor, so at some point the payors will not be bound by the definition of medical necessity within the settlements.
"I encourage physicians to play an active role in writing the appeal letters for claims that have been denied due to medical necessity, as you do not want to leave that to the discretion of a non-clinician," says Mr. Weiss. "However, for the practices that still cannot get the physician to write the appeal letter of medical necessity, there is simple language practice staff can use."
5. Re-submit or appeal denied claims. Don't leave money on the table by tossing denied insurance claims. If the claim was denied for a coding error, fix the mistake and resubmit; if it was denied for another reason, appeal the payor's decision as far as possible."Insurance companies are making up bogus algorithms to deny surgery, and I don't know where they are coming from," says Hooman Melamed, MD, an orthopedic spine surgeon with DISC Sports & Spine Center in Marina Del Rey, Calif. "They aren't paying attention to the clinical notes and they are saying surgery isn't indicated, when clearly the findings are there. They are doing it hoping the patient and surgeon will give up and the surgery won't be performed. I've had denials for fusion in scoliosis and other deformity procedures where patients failed conservative therapy and they are still telling me the patient isn't a surgical candidate."
It's important to fight for coverage from the preauthorization stage, but just receiving the go-ahead for surgery doesn't mean your work is over.
"Keep in mind, pre-certification approval is in no way a guarantee of payment once the services have been rendered and a claim has been submitted for reimbursement," says Mr. Weiss. "That is why it becomes critical for them to have staff that is highly educated and trained in the 'business of medicine' so they can have the requisite skills necessary to secure the reimbursements the presence has emitted you to."
More Articles on Spine Surgeons:
Outlook for Spinal Non-Fusion Technology Trends: Q&A With Joe Ross of LDR
5 Factors Influencing Spine Fellows Turn Towards Academia
5 Spine Surgeons on Enduring EMR Adoption