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Top 7 Challenges in Spine and Pain Coding June 3, 2015

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Top 7 Challenges in Spine and Pain Coding June 3, 2015 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 • 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 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 Joint 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 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 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 syndrome 721.0 cervical spondylosis w/o myelopathy 723.8 Other syndromes 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 headache 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) joints 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 Surgery: 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 physical therapy • 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
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