How often have you tried to get reimbursed for a spine procedure only to be told that the reimbursement won't be forthcoming because the spine procedure is not covered or that prior authorization was needed according to the patient's policy? But, wait: When you first called you were told that authorization was not required.

Many frustrating reimbursement denials are the result of medical policy guidelines that won't cover procedures in an outpatient setting, even though insurance reps didn't tell you that at the time. Additionally, denials may be the result of poor communication between facilities and payors or a research failure by insurance carrier reps to identify policy guidelines for particular patients.

Since the ability to perform spine procedures in an outpatient or ambulatory setting is a relatively recent event, and with more and more spine surgeons, injectionists and interventionalists using this setting, the possibility of denial is likely due to many different factors, some outside of your control — such as when a payor denied a claim because the insurance carrier representative didn't know the difference between anterior and posterior. So let's focus on what you can control to improve your odds of reimbursement success.

1. Taming the preauthorization process. The facility denials that we've audited and tracked reveal significantly high percentages were related to preauthorization or a lack thereof. There were patterns that indicated this process was flawed on both the facility and carrier ends. Develop a rigid preauthorization process that requires all scheduled procedures go through a complete and documented protocol. Don't depend solely on the physician's practice to provide the authorization needed for reimbursement to your facility. All the information needed to preauthorize should be standardized to include the phone number called, the date and time of the call to the carrier, the name and corporate title of the representative handling the call and the CPT codes to be authorized that have been provided by the surgeon or the physician. Being prepared with all of this will help to eliminate some of the misunderstanding of the cases to be performed in the outpatient setting. Careful documentation of the conversation, including a confirmation in writing or a reference number of the call, is absolutely necessary to support your appeal if you believe that you've been denied inappropriately. This documentation has provided us with monumental success in appealing reimbursement denials that had resulted from the receipt of inaccurate information from the carrier during the preauthorization process.

2. New technology. Other denials that are becoming commonplace involve new technology. New technology in spine has led to an increase in newer procedures that are often performed on an outpatient basis. Be aware that reimbursement for these procedures may be acceptable to some carriers, but not to others. When calling to get authorization, it's critical that you inform the carrier of the actual procedure via the CPT codes that you'll be submitting. Unfortunately, many policies don't require preauthorization in an outpatient setting, but they also don't cover new technology or "experimental" treatments. So as your staff is following rigid preauthorization protocols, they're unaware of the high probability of denial if the facility doesn't secure a valid, case-specific authorization for new technology.

An example of this would involve insertion of posterior spinous process distraction devices, which CMS covers, but many commercial carriers typically deny. Even though preauthorization isn't required for outpatient service according to the insurance representative, the carrier won't cover these procedures, with or without the standard approval letter, as only a code (CPT 0171T) and patient-specific authorization will suffice.

Remember that the authorization received is not a guarantee of payment. It is critical to check the policy guidelines for new technology for every single payor. If the representative states that you don't need one, and you accept that, be prepared for a reimbursement failure.

3. Surgeon's operative note. Oftentimes you can blame receiving less than maximum reimbursement on the lack of detail in the surgeon's operative note. Here are some rules to follow before — and after — you submit a claim:

• preauthorize the procedure and codes correctly;
• document all insurance conversations (date and names of all involved);
• ask for authorization in writing;
• dictate immediately;
• document all procedures, in an acceptable order (by this, I mean a cohesive listing of the procedures in the order that follows the documentation of the surgical case);
• describe the procedures in context of the codes; for example, 63030 represents laminotomy, foraminotomy and partial facetectomy;
• code correctly and submit claim along with operative notes swiftly;
• incorporate a strong collection process; and
• appeal aggressively.

4. Medicare cases. Other surgical procedures that have been standard in the spine community may have been performed as an inpatient procedure for the longest time and now can be successfully performed in an outpatient setting with great results. Many commercial carriers have transferred anterior cervical decompression and fusion to an outpatient procedure from its previously designated inpatient status. Surgeons have had great results and patients like the ability to go home quickly to recuperate. But while many carriers are reimbursing for these cases, CMS doesn't consider this procedure an outpatient procedure and won't reimburse the surgeon, facility or any other "billable" service performed during this case. It is necessary to review the OPPS guidelines for spine procedures to see if the case involving a Medicare recipient will be covered. This is the only way to avoid denials for Medicare patients, as CMS doesn't offer preauthorization.

Spine reimbursement game
As new spine techniques and implants evolve, expect the coding and reimbursement challenges to keep pace over such issues as multiple procedure reductions, levels of fusions billed and instrumentation types. Denials generally come in the form of incorrect code pairing, incorrect preauthorization and lack of documentation. Your coders must be able to understand and adequately argue the procedures' eligibility and your surgeons must appreciate the tremendous impact that proper operative report documentation has on the reimbursement process.