July 12, 2024
Auditing Complex Surgeries
By: Jennifer McNamara, CPC,CCS,CRC,CPMA,CDEO,COSC,CGSC,COPC,CPC-I
Medical Auditors are important members of the revenue cycle. They are responsible for monitoring coding and billing compliance and helping to reduce financial risk in healthcare organizations. Seasoned auditors will review highly complex services, such as surgeries performed on the spine. These surgeries require constant auditing and review due to their complexity and high revenue potential for surgeons.
It’s one thing to get the codes correct and quite another to address how to get paid by individual insurance payers. Auditors need to know if the documentation supports the submitted codes and will address missed insurance payer requirements, which may have led to improper payment.
Importance of Accurate Documentation and Coding
Regulatory Requirements enforced by the Centers for Medicare & Medicaid Services (CMS) and state-specific guidelines mandate precise documentation and coding practices.
Non-compliance consequences are severe, ranging from hefty fines to legal action and other serious consequences. Regulatory agencies like CMS will conduct audits, so being ‘audit-ready’ will help you reduce risk. This means you will have all the necessary documentation and coding practices in place to pass an audit. It is a proactive approach to compliance that can significantly reduce the risk of negative audit findings. Accurate documentation and coding are the keys to being audit-ready.
Common Documentation and Coding Issues
When auditing complex procedures, auditors must be able to identify inconsistencies or missing information contributing to coding and billing errors. Some of these errors include incomplete or inaccurate documentation, incorrect use of modifiers, and lack of medical necessity. Let’s look at these common errors and how to avoid them.
- Incomplete or Inaccurate Documentation: Incomplete documentation can lead to coding errors, denied claims, or incorrect reimbursement. Auditors should look to see that all surgery details, including preoperative and postoperative care, are thoroughly documented. The medical necessity prompting the surgery should be documented in the history or indications paragraph of an operative note, along with the findings after the procedure.
- Incorrect Use of Modifiers: Modifiers provide additional information about the procedure performed. In various circumstances, they can either increase (e.g., Modifier 22) or decrease a payment (e.g., Modifier 52). Auditors will often verify that the appropriate modifiers were applied to accurately describe the procedure’s circumstances.
- Lack of Medical Necessity: Documenting the medical necessity of a procedure drives reimbursement. Auditors are responsible for ensuring that the CPT/HCPCS code and ICD10-CM code are reflected accurately and that they follow industry regulations and policy guidelines. For example, many payers follow coverage guidelines identifying payable diagnosis codes for a given procedure. If not followed, the claim may be denied as not medically necessary, creating risk to the organization and having to pay back funds already received and allocated to practice expenses.
- Coding Complexities: Complex surgeries often involve multiple procedures and require detailed coding. Accurate coding requires understanding various CPT (Current Procedural Terminology) codes and guidelines that reflect the procedures performed. This can be challenging due to the complexity of the surgeries and the need to capture all the procedures performed accurately. This is why auditors must be well-versed in the coding guidelines and thoroughly understand the procedures to ensure accurate coding.
They also need to understand:
- Approach: How did the surgeon access the surgical site (Open Incision or via endoscopy)
- Surgical Terms that are inclusive and not indicative of additional reportable services( Fluoroscopy, pain blocks, etc., Closure)
- Identifying services that bundle or are components of a more extensive procedure due to unrelated anatomy, separate incisions, and separate lesions
Complex Surgery Thought Process
Let’s look at a complex spinal fusion procedure and the thought process of an auditor.
*We will not provide the complete operative note; we will advise you on isolating specific areas in your unique operative note.
The following is a list of procedures performed during a single surgery and the codes reported.
- Use of instrumentation to vertebral body segments at L2-L3, L3-L4, L4-L5 (22842)
- Laminectomy, bilaterally, L2-L3 (63047)
- Laminectomy, bilaterally, from left to right-sided at L3-L4 (63048)
- Laminectomy, bilaterally, left to right-sided at L4-L5 (63048)
- Posterolateral lumbar fusion L2-L3, L3-L4, L4-L5 (22612,22614×2)
- Posterolateral bone graft using autograft, allograft (20936,20930)
- Use of operative microscope.
An auditor has reviewed the above coding, which will be discussed in the following thought process.
What should an auditor look for to assess the correct coding for the above procedures?
The first step in assessing whether the procedure codes were abstracted correctly is finding the documented approach for the Lumbar fusion. There are different methods for lumbar fusion that need to be considered:
22612 Arthrodesis, posterior or posterolateral technique, single interspace; lumbar
22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar
22630 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar
In the above example, the documented technique will need verification. A posterior technique without an interbody device will only get you a 22612 for the lumbar spine location for the first interspace or spinal level and an add-on code 22614 x 2 for the additional levels once you can identify all indicated levels. Suppose the body of the operative note identifies that an interbody device (eg. cage or implant ) was used in the fusion. In that case, as appropriate, you can look to 22630 or 22633 for the first level and 22632 or 22634 for the additional levels.
How would you then choose the correct code?
As you can see, the difference is whether the device is inserted using a posterior approach (22630) or a combined technique (22633) of a posterior or posterolateral approach. Without using an interbody device, we will confirm the 22612 and 22614 x2 being coded.
How would you assess if the laminectomy is billable simultaneously with the arthrodesis procedure?
The description of CPT for 22630 and 22633 indicates that they include a laminectomy performed solely to access the disc space. An auditor needs to understand the anatomy of the Lamina, the part of the vertebra forming the posterior vertebral arch. During the procedure, It is removed to relieve pressure on the spinal cord, nerve roots, or cauda equina.
Once you can confirm a complete decompression has taken place, you can justify billing the laminectomy.
The newest codes added in CPT for this procedure, though, are 63052 and 63053 to show that the laminectomy was specifically done during an interbody fusion for decompression. Our example does not indicate a laminectomy with interbody fusion, so which code is appropriate?
If, in the above-chosen codes of 22612 and 22614 x 2, we confirm that no interbody device was chosen and that the laminectomy was performed for decompression, and this can be confirmed with a diagnosis such as Lumbar Stenosis (e.g., M48.061), then we can approve the code choice of 63047 and 63048 x2 if all moving segments are decompressed.
If an interbody device was not used, how was the fusion performed?
CPT code 22842 is coded for Posterior segmental instrumentation that will provide stability for the spine. In 22842, the instrumentation (rod, hook, wire) touches each vertebral body for stabilization.
Is there any other documentation to confirm?
Usually, the final step in coding a fusion procedure is to assess whether the correct grafting code was used. A bone allograft or osteopromotive material can be placed and separately reportable. Surgeons may also add autograft, taken from the patient’s body, and could be seen in documentation as harvested locally from the ribs, spinous process, or lamina through the same incision.
Are there any regulatory or payer requirements that must be met?
Any seasoned auditor will review the documentation and identify if billing the code will violate a policy or regulation. The Centers for Medicare and Medicaid Services have determined whether or not a code is payable or included in the work of the primary procedure. The codes 20930 and 20936, often billed, are considered Status B by CMS, and if you were to look them up in the fee schedule, you would see that they cannot be processed due to their payment status. For more information on status B, please review the Internet Only Manual 100-04 Chapter 23-30.2.2.
On the other hand, a grafting procedure such as 20937 (Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) will be payable as it is performed through a separate incision unlike the previous codes mentioned.
Most auditors would not recommend submitting 20930 or 20936 on the claim as they would not be covered and would increase the payer’s audit risk if billed. An auditor has an obligation to advise a medical practice that billing for non-covered or non-payable services is fraudulent when a policy exists and is expected to be followed.
Auditing complex spine surgeries requires a thorough approach and understanding of the latest guidelines and best practices. Auditors can use resources from CMS, AMA, and AAOS, for example, to be detailed in their auditing processes, ensure compliance, and optimize reimbursement. Regular training and staying updated with the latest coding changes are important to maintain accuracy and efficiency in surgical documentation and coding. I hope dissecting the above complex operative scenario has given you a new appreciation of what auditors do and their importance. Happy Auditing!
*CPT® is a registered trademark of AMA
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