Orthopaedic surgical practice that fail to pay close attention to the surgical pre-authorization process may find themselves drowning in denied claims for procedures that were coded correctly. Why? The answer may be that the wrong CPT codes were submitted to the insurance carrier during the pre-authorization process.
Consider the Costs of Missed Codes for this Surgical Procedure
A patient with a diagnosis of lumbar spinal stenosis and degenerative disc disease is scheduled for surgery and the surgeon fills out a surgical scheduling sheet that reads as follows: Posterior fusion, L4-5, L5-S1 with decompressive laminectomy, pedicle screw instrumentation, possible TLIF. There is a lot to unpack here. Let’s start with the posterior fusion.
The CPT codes for a two level posterior lumbar fusion are 22612 for the primary level (L4-5) and 22614 for the additional segment (S1), but what about the possible TLIF (transforaminal lumbar interbody fusion? If the doctor performs a TLIF at L4-5 and posterior fusion at L5-S1, the code are 22633 and 22614, but if TLIF is performed at both levels, you will need to pre-certify codes 22633 and 22634. When TLIF is performed, an interbody implant is used. If the surgeon will be using PEEK cages, you will need approval for code 22853 for each level.
If the patient is having a decompressive laminectomy for spinal stenosis at two levels, the correct codes are 63047 and 63048, but only if posterior fusion is performed. If decompression is performed at the same levels where TLIF is performed, the codes change to 63052 and 63053.
For the posterior segmental instrumentation at L4-5-S1, you’ll need approval for code 2284
Lastly, you need to find what type of bone graft material the surgeons intends to use and obtain pre-certification for the appropriate code(s) from the 20930-20938 range.
Impact on Reimbursement: Failing to pre-certify all of the possible fusion and decompression codes could cost the practice substantial income. For example, if the “possible TLIF” is performed and you failed to obtain approval for codes 22633, 22634, 63052, 63053, and 22853, the cost to your practice will be significant. The total Medicare allowed amounts for these CPT codes is $3339.59; the allowable from a private payer would be significantly higher so you can see how much is at stake to your practice is you do not obtain approval for all procedures that are both planned and possible.
The bottom line: Always keep an open line of communication with your orthopaedic surgeons to clarify any questions or concerns about proper coding for surgical pre-certification. If you are unsure about what procedures may be performed, ask the surgeon.