At the 12th Annual Spine, Orthopedic and Paine Management-Driven ASC Conference in Chicago on June 14, Carolyn Neumann, senior manager of coding and coverage access for Specialty Healthcare Advisers, discussed reimbursement challenges in joint and spine surgical coding.
Here are three of the reimbursement issues Ms. Neumann addressed.
1. Syncing up surgeon and facility billing. There are two pathways to reimbursement: through the surgeon (CPT codes) and the facility (inpatient MS-DRG codes and outpatient/ambulatory surgery center codes), according to Ms. Neumann. Communication among all parties involved is crucial for correct reimbursement, especially when the two pathways blend in the case of surgeon-owned ASCs. "I think for surgery centers and any other outpatient setting, communication is number one," she said.
2. Considering coverage as well as codes. Ms. Neumann said it's important for providers to consider payers' coverage policies as well as codes. "Just because there's a code doesn't mean there's coverage," she said. This applies to Medicare as well as private payers, which can have rather convoluted coverage policies, she said.
3. Coding and billing for allograft products. Although allografts are up-and-coming in all orthopedic and spine situations, there isn't CPT coding in orthopedics yet to capture these procedures, Ms. Neumann said. Orthopedic repair and augmentation procedures, for instance, have no separate CPT coding for the application of allograft. Ms. Neumann said the possible use of modifier 22 or the use of an unlisted code (which will require payer review) are the options if allograft application increases service significantly. Some allograft products also have "Q" codes. These options are something providers should consider when developing contracts with payers, according to Ms. Neumann.
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