Top 7 Challenges in Spine and Pain Coding June 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 Overview

• Tough coding issues • • 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 2 Tough Coding Issues: 1 - Anatomy

3 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

4 Transforaminal Epidural and Paravertebral Facet Injections

5 Anatomy of the Spine

6 Anatomy of the Spine (cont.)

7 Tough Coding Issues: 2 - Documentation Challenges

8 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 cloning 9 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

10 Proper Documentation: Medial Branch Blocks

11 Proper Documentation: Medial Branch Blocks

12 Tough Coding Issues: 3 – LCDs, NCDs and Payor Policies

13 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

14 Example: LCD vs. Payor Medical Policy

Procedure Note Chief Complaint: bilateral 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

MCR LCD ID L35336 Payor Medical Policy Diagnosis to support medical necessity: Diagnosis to support medical necessity: 716.98* unspecified arthropathy involving other 723.1 Cervicalgia specified sites 723.2 Cervicocranial 721.0 cervical spondylosis w/o myelopathy 723.8 Other affecting cervical region 721.1 cervical spondylosis w/ myelopathy 724.2 Lumbago 721.2 thoracic spondylosis w/o myelopathy 724.3 Sciatica 721.3 lumbosacral spondylosis w/o myelopathy 724.5 Backache, unspecified 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

15 Medicare LCD ID L35336 (cont.)

• Medical necessity ICD-9 codes asterisk explanation: • 716.98* • Use for FACET ARTHROPATHY • 723.8* • Use for Occipital with CPT 64490 only • 724.8* • Use for FACET SYNDROME ONLY • 733.82* • Use for PSEUDOARTHROSIS ONLY

16 Example: LCDs

• Therapeutic phase; • Maximum of five (5) facet joint • Only when dual MBBs provide 80% procedures should be injection sessions inclusive of relief of the primary or index pain MBBs, IA injections, facet cyst and duration of relief is consistent repeated as medically with the agent employed may facet necessary; no more than four rupture and RF ablations may be performed per year in the joint denervation with RF medial (4) injections of any type per branch neurotomy be considered. region per patient per year. cervical/thoracic spine and five (5) in the lumbar spine. • Repeat RFAs at same joint will only • CPT 62310 – CPT 62311 be considered medically necessary • Injections may be repeated if if the patient experienced 50% the first injection results in improvement of pain and specific significant pain relief (>50%) for ADLs documented for at least 6 at least 3 months. months. • CPT 64490 – CPT 64492 • CPT 64633 – CPT 64634 • CPT 64493 – CPT 64495 • CPT 64635 – CPT 64636 ESI MBB RFA

17 Example: LCDs ESI

•In the first year, up to six (6) •No more than three (3) •Therapeutic, series of three injection sessions per region epidurals may be performed (3) ESI may be given min. may be performed; up to in a 6-month period of time interval of two (2) weeks two (2) diagnostic and up to •No more than six (6) ESI •No more than two (2) levels four (4) therapeutic session (therapeutic and/or on any given DOS (unilateral •In the following years, up to diagnostic) may be or bilateral) four (4) therapeutic performed in a 12-month •A series of three (3) ESI may injection session per region period of time regardless of be repeated at six (6) month may be performed the number of levels intervals Cahaba Noridian First Coast

18 Example: LCDs Medial Branch Blocks

•In the first year, up to six (6) •A maximum of five (5) •Diagnostic phase should be injection session may be sessions per year in the limited to three (3) levels for performed in the lumbar cervical/thoracic and five (5) each anatomical region region: up to two (2) in the lumbar •No more than three (3) diagnostic and up to four (4) levels (unilateral or bilateral) therapeutic per anatomic region on any •Following years up to four given DOS - therapeutic and (4) sessions may be no less than 90 day intervals performed Cahaba Noridian First Coast

19 Example: LCDs RFAs

•A maximum of two (2) •No more than two sessions •No more than two (2) sessions per nerve level per will be reimbursed in any treatments , right or left, year may be performed in calendar year involving no within a 12 month (365 the lumbar region more than four (4) per days) period of time session (either two (2) bilateral levels or four (4) unilateral levels)

Cahaba Noridian First Coast

20 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 : Trigger Point Injections

CPT/HCPCS Codes 20552 Inj trigger point 1/2 muscles 20553 Inject trigger points 3/>

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 21 Trigger Point LCD: Cahaba(cont.)

720.1 SPINAL ENTHESOPATHY For the following muscle groups use 723.9: · Trapezius (upper & lower) · Sternocleido-mastoid (cervical & sternal) · Masseter · Temporalis · Lateral pterygoid · Splenii · Posterior cervical · Suboccipital 723.9 UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK 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 22 Trigger Point LCD: Cahaba(cont.)

726.39 OTHER ENTHESOPATHY OF ELBOW REGION For the following muscle groups use 726.5: · Glutei, piriformis · Adductor longus & brevis 726.5 ENTHESOPATHY OF HIP REGION For the following muscle groups use 726.71: · Soleus · Gastroenemius 726.71 ACHILLES BURSITIS OR TENDINITIS For the following muscle groups use 726.72: · Tibialis anterior 726.72 TIBIALIS TENDINITIS 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 For the following muscle groups use 726.90-726.91: · Rectus femoris · Vastus intermedius · Vastus medialis · Vastus lateralis (anterior & posterior) · Biceps femoral 726.90 - 726.91 ENTHESOPATHY OF UNSPECIFIED SITE - EXOSTOSIS OF UNSPECIFIED SITE 23 Trigger Point LCD: NGS

Source: Part B - NGS - MAC J6 Jurisdiction Chapter: ILLINOIS Subject: Pain Management MINNESOTA Policy Number: L28529 WISCONSIN Version: 2014-12-16 -

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

24 Tough Coding Issues: 4 – Medical Necessity

25 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 • Medication therapy • MRI findings

26 Tough Coding Issues: 5 – NCCI Edits

27 Applying NCCI Edits

• What is your facility’s policy? • NCCI or not? • Know how your carriers code • What about workers’ compensation?

28 Tough Coding Issues: 6 – Implants

29 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 neurostimulator electrode 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

30 Spine Coding Implants (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

31 Tough Coding Issues: 7 – Approaches & New Technology

32 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) 33 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

34 Spine Coding: Technology

• Technological advances have created new spine instrumentation being used to perform • Older technology – Interbody spacer made of PEEK (CPT 22851) or (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

35 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

36 ICD-10

37 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 – 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

38 Spine Coding Opportunities

39 Spine Coding: Opportunities

• 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)

40 Spine Coding: Opportunities (cont.)

• CMS approved the addition of 10 spine codes to the ASC payable list: 22551 Neck spine fuse & remove bel c2 22554 Neck spine fusion 22612 Lumbar spine fusion 22614 Spine fusion extra segment 63020 Neck spine disk surgery 63030 Low back disk surgery 63042 Laminotomy single lumbar 63045 Removal of spinal lamina 63047 Removal of spinal lamina 63056 Decompress

41 Discussion

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