For surgery centers, billing spinal surgery can be as complicated as performing a lumbar spine fusion. That's because CMS failed to include some of the codes for spinal procedures commonly performed together with the codes it added in its ASC 2015 payment rule. Here's what you need to know about listing excluded services on a claim with covered services.
CMS adds 9 spine codes
In its ASC 2015 payment rule, CMS finalized the addition of the following 9 spine codes as separately payable, effective Jan. 1, 2015:
|22551||(Neck spine fuse&remov bel c2)|
|22554||(Neck spine fusion)|
|22612||(Lumbar spine fusion)|
|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 spinal cord)|
CMS also added 2 other codes to the ASC payable list: 22614 (Spine fusion extra segment) and 63044 (Laminotomy, additional lumbar). These codes, however, are not separately payable since they have been packaged with other codes on the list.
Additionally, CMS agreed with the Ambulatory Surgery Center Association's assessment that CPT codes 22551, 22554 and 22612 were assigned to the wrong ambulatory payment classification (APC) group in the proposed rule and moved these codes to APC 0425, which has a higher reimbursement than the group to which they were originally assigned.
But because spine cases often have multiple codes associated with one case, the new additions have made billing for these procedures tricky. The 2015 rule left many wondering how to submit claims to Medicare for their spine cases since only some of the procedures commonly performed together have made the list.
Billing for complicated spinal cases
The inclusion of some, but not all, of the spinal codes is problematic. Take, for example, a spine surgeon who performs a medically necessary anterior cervical discectomy and fusion surgery (CPT 22551 and 22552), with morselized allograft (CPT 20930), application of intervertebral biomechanical device (CPT 22851) and anterior instrumentation of 2 to 3 vertebral segments (CPT 22845) in an ASC.
We know that 22552, 20930 and 22851 are routine components of the main code, 22551, and that most surgeons often use the anterior plate with or without the cage when performing the core procedure. Cases like this bring up a lot of questions. Would Medicare reimburse the center for only the codes listed in the payment rule and exclude the others, or would the entire claim be rejected because it included codes not payable?
Listing excluded services on a claim with covered services would not typically result in a claim rejection, according to staff at CMS headquarters in Baltimore. Instead, only the lines that are excluded from payment in ASCs would likely be rejected.
But if that's the case, what's the best way to submit ASC services on the claim form? A good place to start is the Medicare Claims Processing Manual, found in Medicare's Internet-Only Manuals (publication number 100-04, chapter 14, osmag.net/XdVn9S). This manual acts as the primary resource for ASC claims processing, though not everything is spelled out clearly in the manual.
To supplement this information, turn to your Medicare contractors. CMS uses a network of contractors called Medicare Administrative Contractors to process Medicare claims, educate providers on Medicare billing requirements, handle appeals and answer beneficiary and provider inquiries. Part B MACs, which have jurisdiction over a particular geographic area, may have local determinations that result in additional policy or billing instructions.
If your ASC is performing or considering performing spinal cases, contact your MAC to determine how you may be reimbursed and how the MAC processes claims. They could tell you, for example, if there are additional billing instructions for your area.
With these cases, you should also keep in mind the patient's responsibility for codes not covered by Medicare. Be sure to review non-covered codes and notify your patient before the procedure, since he would be responsible for non-covered charges.
In situations where you expect Medicare to deny the payment, you should issue the Advanced Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 to the patient. There are specific guidelines available in the Medicare Claims Processing Manual (chapter 30, section 50) to help you determine if and how you use the ABN.
While the current spine codes are a good start, there's more to be done. After the proposed rule was issued, industry experts argued that it would not be economically feasible for many of the approved codes to be performed in the ASC setting until secondary codes used in conjunction with the primary ones are added to the ASC payable list. With CMS's 2016 payment rule coming out shortly, we hope that CMS includes additional payable spine codes that could clarify claims for these cases.
The American Medical Association, worried about the financial impact the switch to the ICD-10 coding system will have on physicians, has asked CMS for a 2-year grace period after the expected switch in October. The AMA says a grace period would let doctors more easily transition to the complex system without affecting patients' care or their bottom line. The AMA wants an assurance that payments to doctors won't be withheld due to errors, mistakes or malfunctions of the new ICD-10 coding system.
AMA had previously asked the government for another ICD-10 delay, saying the switch will "significantly overwhelm" physicians with its 400% increase in the number of codes used to document diagnosis and treatment of patients.
"We continue to press both Congress and the administration to take necessary steps to avoid widespread disruption to physician practices created by this overly complex and burdensome mandate," says Russell W.H. Kridel, MD, AMA board member. "Coding and billing protocols should never get in the way of patients receiving high quality care."
Reprinted with permission from the Ambulatory Surgery Center Association.