Coding and Costs for Cervical Spine Surgery

Cervical spinal procedures are performed for a variety of reasons. From the coding and billing perspective, knowing what to expect for each phase of the surgical process is vital to forming a knowledgable decision as to the reasonability of the costs both anticipated and actually billed.

  • When evaluating the past medical bills before the settlement processes, you will want to understand the value of the past bills, including the cervical spine surgery.
  • If cervical spine surgery is anticipated in the future, you will want to know all the costs that may be associated with this procedure.
  • There are several factors to be taken into consideration.

Pre-operative Work-up

  • Before any surgery, the patient will likely have seen an orthopedic surgeon more than once. When the decision is made to proceed with surgery, there will be a final pre-operative visit to go over the details and answer questions.
  • Typically, the patient will then go to a primary care provider for pre-operative work-up or “clearance.” This will be a lengthy office visit and may be coded with a new Evaluation and Management (E/M) code CPT[1] 99241 – 99245 or a regular office code such as CPT 99213 – 99215.
  • The pre-operative work-up visit[2] will likely include orders for labs, radiology and electrocardiogram (EKG).

Facility Charges

  • Cervical spine surgery may be done in an in-patient or out-patient setting, depending on factors such as the type of surgery, level of invasiveness, amount of anesthesia, surgeon preference, patient’s co-morbidities, recovery needs and availability of facilities in the area.
  • In-patient facility bills may have a Charge Master billing. URC[3] (usual, reasonable and customary) charges can be researched after determining the correct MS-DRG[4]
  • Out-patient charges may have a long itemized billing. Charges at outpatient facilities are often itemized, although some of the items named may be bundled depending on the CPT code guidelines.

Surgeon Charges

  • The surgeon may have a code and charge for different parts of the operation, although some may be bundled together. CPT code information and research can reveal the correct codes.
  • For decompression by removing bone, disc or repairing cervical spinal bones, there may be one code for the first level (i.e. the space between two cervical bones) and then another code for each additional level.
  • For fusion surgery, there will be one code for the fusion that includes many parts of the operation (bundled) and another code for bone graft. If instrumentation was used, there is a third code. Each of these codes has a corresponding code for additional levels.
  • There may be additional codes for the use of microscopes, bone marrow harvest or for using stereotactic procedures for screw placement.

Assistant to the Surgeon Charges

  • The American Medical Association[5] has a list of each surgical CPT code and a table indicating if an assistant to the surgeon is needed 1) usually, 2) sometimes or 3) rarely. This assistant could be a surgeon, a physician’s assistant or a nurse practitioner. The staff supplied by the operating room is not billable as an assistant to the surgeon.
  • The assistant to the surgeon is only permitted to charge a percentage of the surgeon’s charge, usually 13-20%.

Anesthesia

  • Anesthesia will charge for their time by units and the type of surgery.

Post-operative Care

  • Follow up physician office visits and possibly x-rays: There is a global period[6] following surgery that a physician may not charge for visits in the hospital or in the office. For cervical spine surgery, this is 90 days.
  • Physical Therapy is common after many surgeries and may be recommended for a few weeks or months depending on the surgical procedure and response to therapy.
  • Pain medication is common for the first period after surgery.
  • There may be home equipment such as bone stimulators, elevated toilet seats and grabbing devices.

Dawn Cook RN, Life Care Planner is knowledgeable, skilled, experienced and has training and education in medical damages. She is highly experienced in evaluating past medical bills or projecting medical costs in the future. Contact us if you would like to discuss your case: 702-544-2159.

[1] American Medical Association (AMA): CPT® (Current Procedural Terminology). (2018). Retrieved from https://www.ama-assn.org/practice-management/cpt-current-procedural-terminology

[2] American Academy of Family Physicians, “Documenting and Coding Preventive Visits: A Physician’s Perspective” retrieved from https://www.aafp.org/fpm/2012/0700/p12.html#fpm20120700p12-bt3

[3] URC (Usual, Reasonable and Customary) “The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.” https://www.healthcare.gov/glossary/UCR-usual-customary-and-reasonable/

[4] Centers for Medicare & Medicaid Services (CMS). Defining the Medicare Severity Diagnosis Related Groups (MS-DRGs), Version 34.0. (2016, October 1). Retrieved May 20, 2018, from https://www.cms.gov/ICD10Manual/version34-fullcode-cms/fullcode_cms/Defining_the_Medicare_Severity_Diagnosis_Related_Groups_(MS-DRGs)_PBL-038.pdf

[5] Assistants at Surgery, American College of Surgeons 2018 guidelines of surgeries and need for assistant, retrieved from http://bulletin.facs.org/2018/04/acs-releases-2018-update-to-the-physicians-as-assistants-at-surgery-report/#.WySbyqknZsM

[6] Global Surgery Booklet, describes the global period after surgery when physician additional charges are not allowed from https://www.cms.gov/Outreach-and-Education/…/GloballSurgery-ICN907166.pdf

 

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