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ROADBLOCKS AND CHANGES TO SPINE SURGERY REIMBURSEMENT

Coding and Billing for Spine Surgery; a complicated and troublesome task for most of the healthcare practitioners, isn’t it??

Well, yes it is! While coding for spine surgery medical practitioners or professionals face several huge obstacles in achieving proper and accurate reimbursement for their spine procedures. Many of the claims even get denied by the insurance carriers due to incorrect or inappropriate coding. The biggest barrier to spine surgery reimbursement is the discrepancy in terms for criterion for coverage in spine.

Spine Surgery involves prior authorization. When a claim is submitted, the entire procedure gets denied due to some missing important element. Therefore, prior authorization is becoming necessary as it is a kind of review to avoid any miss happening that can result in claim denials. So payers are demanding proactive documented medical necessity and procedure details so that chances of inappropriate coding reduce.

Another roadblock for spine surgery reimbursement is creation of narrow networks. Narrow Network means there are few surgeons on the panel to provide care to the patients. So if you are not one of those surgeons, your reimbursement will definitely get affected because you won’t be able to find patients.

In this changing era of healthcare, it is very important for the surgeons not to get deselected from the networks in which they are currently serving.

CMS has recently released 2019 NCCI Policy Manual for Medicare Services that includes changes affecting the billing and coding of spinal procedures and services;

  1. Changes have been made to chapter 4 in which CMS has tried to clarify the reporting of CPT Codes 22600-22634 regarding spine procedures
  2. Changes have been made to column one CPT code 22630 and column two CPT code 63056 that states the two procedures cannot be reported together at the same spinal level for the same patient.
  3. If only one procedure is performed, only one unit of service should be reported for the genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.
  4. If no CPT code accurately describes the procedure, the lab must report CPT code 81479 (unlisted molecular pathology procedure) with one unit of service.

As of next year, there is a rule that might take effect eliminating the 99202-99205 and 99212-99215 and giving a combined payment. So, whether you spend 10 minutes or an hour with a patient, doctors will get the same amount. While not final, and may fail, CMS will obviously get something like this passed.

Historically, they have always found a way to get some version of a cut passed. Again, this is the one of the ways of the government cutting doctor’s reimbursements thinking it will save money. Negative incentives have never made behavior more desirable. In this case, it will negatively impact quality of care and make the physician-patient relationship ever more fetid, and not to mention, drive more independent practitioners out of a job.

To Know more about spine surgery coding and it’s reimbursement, join us on our upcoming live webinar on Spine Surgery Coding, will be presented by Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I.

Spine Surgery: Its Anatomy For Proper Billing and Coding

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Coding and Billing for Spine Surgery; a complicated and troublesome task for most of the healthcare practitioners, isn’t it?? Well, yes it is! While coding for spine surgery medical practitioners ...
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