Follow an eight-step formula for correct spine coding

As part of the new Spine Coding Source column, Spine Surgery Today will begin discussing relevant spine coding issues for surgeons. We hope this new feature will enhance your practice and help clarify areas of difficulty. We are pleased to work with coding experts, KarenZupko & Associates. Our goal is to provide our readers with up-to-date coding changes and practice optimization tools. We look forward to your comments and suggestions for future topics.

by Teri Romano, RN, MBA, CPC, and Kim Pollock, RN, MBA, CPC

Reporting the “just right” CPT codes isn’t easy for spine surgeons and coders. In fact, it is complicated. If you under code, in effect, you “pick your own pocket” by losing revenue and/or relative value unit. Overcoding leads to denials, inflated accounts receivable and a possible audit with a payback.

Try this organized approach to answer key questions to submit accurate codes the first time. The benefit of using our technique means you increase the chance of your claim being coded correctly — with no reworks, denials or time-consuming appeals.

If you are in academic practice, share this technique with your fellows and residents. For private practice surgeons, keep the Figure on your phone to use as a dictation prompt to make sure your operative reports have all necessary information. Coders will also benefit by using these eight steps as their guide.

Future articles in the Spine Coding Source column will expand on these spine coding questions.

1. What surgical approach was used?

Was the approach anterior (e.g., anterior cervical discectomy and fusion, anterior lumbar interbody fusion, corpectomy) or posterior (e.g., laminectomy, fracture repair)? Or did the surgery have both an anterior and posterior component (a front-back procedure at the same operative session)? Did you use a traditional open approach, or a minimally invasive or percutaneous approach? Does the documentation indicate direct visualization (and open or minimally invasive approach) or was visualization via fluoroscopy? Which spine code best reflects the approach used?

2. Where in the spine was the surgery performed?

Was the procedure performed in the cervical, thoracic, lumbar or sacral area? Are codes specific to the area of the spine? Did the surgery cross a junction of the spine (e.g., T10-L2)? If so, can both areas of the spine be coded since it had both a thoracic and lumbar component? If so, is a modifier needed? If not, which area should be selected as the primary code?

3. How many levels of the spine were treated?

What makes an additional level? Is the procedure coded by vertebral segments, interspaces or regions of the spine? If add-on codes are appropriate, how many were documented? What modifiers, if any, are needed?

4. Was there a decompression performed and for what diagnosis?

If a decompression was performed, which decompression code is most appropriate? Does the patient’s diagnosis impact the choice of decompression code? If more than one decompression procedure is performed at the same level (for example, a fracture reduction and laminectomy or a laminectomy for both disc and stenosis), can both be coded? If so, what modifiers are used?

5. Was an arthrodesis/fusion performed?

If yes, then was it anterior, posterior, interbody or a combination of these? What needs to be documented to justify a fusion? If more than one type of fusion is performed, then can each be coded? And if so, is a modifier needed? What about additional levels? Are additional levels coded by segment, interspace or some other approach? If both a decompression and fusion are performed at the same level, can both be reported? If so, is a modifier needed? What about a lumbar interbody body fusion and a decompression? Can both be billed and does the documentation justify both?

6. Was instrumentation or fixation placed?

If instrumentation or fixation was placed, then was it posterior, anterior, intervertebral or interbody and how should each be coded? What about new technology? How are newer fixation devices coded?

7. Were bone grafts harvested and placed?

If a fusion was done, then what bone grafts were harvested and used? Was more than one type of graft used and if so, can each be coded? If certain types of bone graft harvest are bundled by some payers, should they be billed?

8. Were other billable procedures performed and documented?

Was the operating microscope used for microdissection? Was bone marrow aspirate harvested and if so, from where? Was stereotactic navigation performed to place pedicle screws? What about fluoroscopy? Was neuromonitoring performed? Which of these was documented and which is appropriately coded and billed by the operating surgeon?

Stay tuned for future articles in the Spine Coding Source column of Spine Surgery Today that will expand on these spine coding questions and offer guidelines for accurate coding and documentation for spine procedures.