July 1996 Bulletin

Staff must know coding process

Need accurate detailed information about procedure

by Beverly J. Stone

Beverly J. Stone is an independent coding consultant based in Kerrville, Texas.

Since all health care reimbursement is based on the principles of coding, the coding efforts of health care providers should be an area of major focus. Unfortunately, many providers continue to view coding as a negative task when it should be considered a positive task.

For a health care provider to be a financially successful business, all employees must understand the importance of their involvement in the coding process. Although every employee may not be expected to become a coding expert, they should attain a level of proficiency to recognize the need for accurate, detailed information. Excuses often verbalized by employees that they are either "too busy" or "it's not in my job description" have long become passé and should be interpreted as a lack of knowledge. In all fairness, each employee must be given the proper tools to utilize in an effort to supersede dated thinking and to achieve an acceptable success rate.

What does it take to code effectively? Accurate detailed information about the procedures performed and the reason(s) they were performed is essential. The lack of details about a surgical procedure is the cause of most erroneous coding. For example, since many surgical procedures can be performed via different approaches, it is important to indicate the surgical approach used. Also,
it is necessary to clearly identify any adjunct procedures performed in conjunction with the primary procedure.

Procedure performed: Arthrodesis L3-S1 with bone graft and instrumentation.

Based on the above description, this surgery could not be coded properly without the following clarifications.

Is the arthrodesis approach technique by:

Is the bone graft:

If done by posterior approach, is the instrumentation:

The number of vertebral segments/interspaces the procedure(s) was performed on also must be calculated correctly because it is not uncommon for there to be multiple code choices or adjunct codes based on the number of vertebral segments/interspaces involved.

Procedure performed: anterior spinal arthrodesis, L3-S1 autograft, morselized, separate incision anterior instrumentation, 3 vertebral segments.

With the procedure stated in this manner, the coding staff is able to assign the correct codes as identified by their CPT descriptions. This eliminates both the reading of lengthy operative reports and errors in interpretation.

Coding:

22558 Anterior Spinal Arthrodesis, Lumbar, 1 Interspace (L3-L4)

22585 Additional Lumbar Interspace (L4-L5)

22585 Additional Lumbar Interspace (L5-S1)

20937 Autograft for Spinal Surgery, Morselized, Separate Incision

22845 Anterior Spinal Instrumentation, 3 Vertebral Segments

Five CPT codes are required to accurately report the procedure(s) performed. Also note, codes 22585, 20937, and 22845 are considered adjunct codes. Therefore, modifier 51 (Multiple Services) is not appended to these codes because they cannot be reported as "stand alone" procedures.

Once all of the CPT codes are selected, it is important to link them to complete (i.e., to the level of greatest specificity) ICD-9-CM diagnostic codes. Most insuring entities will deny or question a claim if the ICD-9-CM code does not indicate medical necessity for the procedure performed.

Orthopaedic surgeons frequently use codes from both the Musculoskeletal System and Connective Tissue chapter and the Injury and Poisoning chapter. Many of the conditions listed require the use of fifth digits to indicate some specific aspect of the overall condition. Failure to use the fifth digits as directed will cause your claim to be denied. The ICD-9-CM codes are truly as important as the CPT codes for the claim to be reimbursed.


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