How to Capture the Spine Surgery Reimbursement You Deserve

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Spoiler alert that isn’t really a spoiler alert: The documentation in your op note will make or break your revenue cycle management team’s success.

Are you feeling down about one of this past summer’s biggest reimbursement bummers? The proposed Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2024 cuts Part B payments to physicians.

The proposed PFS reduces overall payment rates by 1.25 percent in CY 2024 compared to CY 2023. The conversion factor for CY 2024 is $32.75 — a $1.14 decrease from the 2023 conversion factor of $33.89, writes Renee Dustman, managing editor at the AAPC.

In contrast, hospital outpatient departments and surgery centers will see billions in new revenue in 2024, STAT News estimates. HOPDs and ASCs will get a 2.8 percent pay increase. Other health care sectors will get increases too. Only physician services will take a cut.

Now more than ever, spine surgeons and RCM teams need to work together to make sure they garner the reimbursement that is available.  

 

Spine Surgery Documentation Tips from an Expert

Here’s help.

We spoke with Chris Boucher, MS, CPC, editor of  Orthopedic Coding Alert, and other specialty coding publications. Chris alerts coders and billers to CPT^® code revisions, NCCI edits, payer policies, and other updates that affect reimbursement for the work surgeons do. Chris’s articles help coders understand how to code accurately and compliantly, how to reduce denials, and how to audit-proof claims–even as they optimize reimbursement opportunities.

Coding from op notes is a frequent topic for Chris and his readers. He understands that a physician’s focus is treating patients, and that payers often demand documentation that isn’t clinically relevant. But missing or unclear documentation in your op note can hamstring coders working to secure your reimbursement. He shares these tips for smoother communication between spine surgeons and the medical coders who are working to get them paid.

Don’t forget to document each interspace you treat with arthrodesis below C2.

When a surgeon performs cervical single-interspace arthrodesis below C2, the coder reports it with CPT® code 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2).

If you treat more than one level, be sure your op note mentions each level you treated.

Reimbursement Reason: Code 22551 will reimburse you for one level only. To secure reimbursement for additional levels beyond the first, your coder needs to report add-on code +22552 (… cervical below C2, each additional interspace (List separately in addition to code for primary procedure)).

Mention any grafts and instrumentation you use during arthrodesis.

Have you deployed an intervertebral biomechanical device, spinal cage, or anterior instrumentation that is separate and not an integral component to the biomechanical device? If so, make sure it’s clear to the coder who is working from your op note.

Reimbursement Reason: Your medical coder needs to report an add-on code to secure payment for instrumentation that’s not included in 22551/+22522. For example, your coder might need to append +22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)).

Help your coder capture reimbursement for E/M that happens prior to percutaneous vertebroplasty/vertebral augmentation surgery.

If your RCM team uses time for code selection, mention time in your documentation so that your coder can report the appropriate evaluation and management level. Be sure to mention any imaging or X-ray that happens before surgery.

Reimbursement Reason: You deserve to be paid for all the diagnostic work and medical decision making you did prior to surgery. If you don’t mention that work in your notes, the coder may code only for the surgery itself — codes in the 22510-+22515 series.

Performing a total disc arthroplasty instead of full fusion and fixation?

Document the diagnostic work that led to your medical decision. If using time to select the appropriate E/M level, document time. Don’t forget to document imaging and X-rays so that your coder can select the proper codes–72141, 72125, or 72040, for example.

Help your coder express medical necessity to payers: Don’t forget to document information that will help your coder select the correct ICD10 code–degenerative disc disease, disc collapse, radiculopathy, or foraminal stenosis, for example. Document any comorbidities that played a part in your medical decision making.

Before they shell out reimbursement for the surgery, payers will also want to see previous attempts to treat the condition in the medical record for that patient, such as PT or therapeutic injections.