[Please do not quote:]RPL, you magnificent bastard, you know exactly how to bait me with someone getting screwed over who doesn't deserve it, don't you? Hi there. How're you doing?
[Looks around, reads, slight grumble, other noise {very possibly a grumble, but unconfirmed}, reads more, sips coffee. Screw it. Operator inbound.... ]
Hello Weird. Good to see you. I do not know if a technical material piece like this would be in a public library, but good thought. Constructive. Informative, as always friend.
\....
Hi again Fem. Long time no see. You were always nice to me.... As this is clearly a theoretical exercise only....
What are you coding for/what insurance in your example? {Answered via other means Medicare, o joy}
Consult your MAC, and ask them. Document that you asked them and their response. What are the dates of service in your example?Context is key in coding, as I imagine you know. I may request more details, especially before thinking of providing anything like a code ... in this example.
______________________________________________________
I imagine you want this thing I probably don't have a copy of: (See page 40 out of 54)
https://commerce.ama-assn.org/catalog/media/cpt-assistant-index-2019.pdf
Spine and Spinal Cord Code Changes, 7, 2012, Jul, 3,
01996, 0274T, 0275T, 0276T, 0277T, 62267, 62287, 62290,
62310, 62311, 62318, 62319, 62367, 62368, 62369, 62370,
63001, 63003, 63005, 63020, 63030, 63035, 63056, 64484,
64633, 64634, 64635, 64636, 72275, 72295, 77003, 77012,
95990, 95991
?
______________________________________________________Back when I most certainly did not help run hospitals if popular belief is to be trusted (O, it is, it is), CPT manuals and the CPT assistant were nice sources on this. I do not know if I have a paper copy or where I might have stored that paper copy, which I most certainly know nothing about. That's my story and I'm sticking to it.
If there is anyone who could locate one? I also would be interested in this. The above documentation may assist anyone helping in this search. Please assist in this assistance __________________________________________________________
Correct coding is an entirely different matter, fraught with difficult (unappreciated) technical matters. Make sure (what I assume to be the physician you are coding for gives you) the operative report copy to double check. I certainly hope no one is pressuring you to code 63056, which is an very invasive procedure code, for something done with an endoscope....
The three things that you need to worry about with this particular fiasco you
inadvertently walked into were likely thrown into through no fault of your own and I'm going to get you out of are as follows.
A.) Correct CodingB.) Experimental and Investigational C.) CYA / whoever threw you into this has (wrong) expectations you will have to manage.A.) Correct CodingNaturally, you will wish to know the operation and methodology performing it, including surgical approach.
The surgical approach is important, as is the area operated on (thoracic or lumbar, etc?).
https://coder.aapc.com/cpt-codes/63056 Exploration/Decompression Procedures on the Spine and Spinal Cord
63055: Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg herniated inter vertebral disc) single segment
thoracic* See CPT Assistant Nov 99:36; CPT changes an insider's view 2000
63056 LUMBAR (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc
63057 each additional segment, thoracic or lumbar (list separately in addition to code for primary procedure
(Use 63057 in conjuction with 63055 and 63056)
AMA CPT 2012 professional edition, p. 323 63056 is an open procedure. Traditionally, I have always understood open procedures to be "cutting someone open" verify for correct coding.
The RVU (relative value units) for 63056 are about 3x more than the next possibly permissible code (3x the cost). Use it if it's the right procedure, but not if it isn't.
The dates of service are paramount, especially in this situation, which I am not commenting upon.
IN 2017, CMS issued a separate code for endoscope procedures like this under CPT code 62380
https://www.health.ny.gov/health_care/medicaid/ebbrac/docs/2017-12-08_endoscopic_decompression.pdf B.) Experimental and Investigational There are certain dangers you must be aware of when coding this particular matter. First and foremost, you must be
absolutely sure this procedure is not a PILD/MILD (percutaneous or minimally invasive), as several insurances do not pay for them (double check with your Compliance Officer). Medicare does not cover PILD/MILD except in a clinical trial with specific registration requirements. Some physicians have tried passing PILDs off as 63055-63056. Don't. The auditors know to look for this and they do not care. Again, review with your Compliance Officer.
IF THIS IS A PILD, which my jaded self can't help but think.... Then this will likely be denied by most insurance as an experimental and investigational procedure (and your doctor will hate this answer but for insurance purposes, meh). And, CMS has already answered this ....
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=269In a move it certainly does not get any credit for, the government considered covering this back in 2013 or so. Wanting to be a responsive and responsible decision making body, they solicited comments from experts in the feild and reviewed every piece of scientific literature they could get their hands on, while asking for more.Summarily the literary evidence was not fantastic, standards were not sufficiently consistent and their methodology was .... we're going to say not great. Basically, it was found not to be covered except in clinical trials to gather more evidence.
CMS also addressed subjective comments from physicians in the feild who favored the procedure and said it should be covered, like so:
"General Issues
Comments: There were numerous comments from physicians who perform the procedure who reported anecdotal good outcomes and few to no complications or adverse events for their patients. A number of commenters pointed out that patients who do not improve still have the option of continuing with non-surgical care or opting for open decompression.
Response: CMS appreciates the input of the many physicians sincerely conveying their personal experience with PILD. However, evidence from well-designed methodologically robust clinical studies is more persuasive to draw confident conclusions about the impact of medical technologies. As we state in the General Methodologic Principles in the Appendix to this decision memorandum, anecdotal reports are subject to biases and do not carry the evidentiary weight of methodologically appropriate clinical studies."
In other words, CMS has heard all of this and steadfastly refused to care in writing.
In the Event that it is percutaenous via an endoscope prior to 2017, but after 2011, then it may be in danger of falling into
0275T (note the category III CPT code for emerging tech and procedures, hence experimental and investigational. If it is prior to 2011, then I fear you may fall into 84.99, which is other procedure on relevant anatomy..... If that's the case, then you need to be very careful, because it will be likely be denied recouped if put under 63056.
More info needed. C.) CYA / whoever threw you into this has (wrong) expectations you will have to manage.You need to review this with your compliance officer, and experienced coding staff, preferably CPC (Certified Professional Coder). Again, ask your MAC for guidance, preferably in writing to CYA. The physician you are coding for may have a strong opinion on this matter. He or she may very well be an excellent doctor, and I assume he or she is. This isn't about medicine, this is about insurance and having someone pay for it. At the end of the day, this isn't about restricting what your physician does, but if the insurance company won't pay for it, or won't pay for it at a higher level billing, then that's an admin issue. Nobody wants an auditor saying things weren't coded. If the physician you are coding for wants this code for an endoscope procedure, then be the following is advised:
I.) Always be respectful, as this physician is very experienced and probably means well, but the insurance (is always blamed on the coder if it goes south)....
II.) CYA, and make sure you have multiple opinions verifying this procedure is the exact code. It isn't about disputing the operation (that's the Dr.'s call), it's what to bill it under.
III.) Respectful diplomacy, while CYAing and documenting to show you did your job.
Summary: MAKE SURE 63056 is the right code. MAKE SURE this is not a PILD. MAKE sure you document to CYA.
Consult your Compliance Officer, and ASK YOUR MAC, before you bill and document that you did so, their response, etc. (See also CYA).
This is not coding advice, but rather an assistance attempt to point you in the right direction, your compliance officer/MAC, and to gather additional information.
Again, I apologize that I do not have the document you requested, but hopefully this helps both generally, and specifically with more information for anyone who can find it. If found, please make available, as I would also enjoy access. Thank you.
[Please do not quote, come on, I'm just dropping in to help a bit and then operator outbound].
Not me and if it was see above about MAD, but....
