Hotline - The Spinal Cord
Coding Direct Connect

Business Dynamics Limited operates a hotline service, The Spinal Cord, staffed by Certified Professional Coders and spine specialists who are considered to be experts in national coding guidelines. This service offers real-time, live support with regard to spine coding, collections, and reimbursement issues. In addition, this service also supplies coding advisories, BDL’s quarterly newsletter, EOB analysis, and documentation review.

Special hotline packages for practices, and facilities that we offer are listed and available for purchase below. Contact us for more information.

FOR Doctors & Practices --
- Can be used for surgery or injection procedures.
- Anterior/Posterior surgery cases count as 2 cases.
- They can submit one at a time or in multiples.
- Package must be prepaid & used within 12 months or expires with no refund. No extensions.

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Billing Questions

• What would be the most appropriate way of coding the removal of instrumentation after a spine surgery?
  Maureen B. Staten Island, NY
• How do you determine the CPT code order on the HCFA form?
  Tara S. Newark, DE
• Can an insurance company dictate policy regarding payment on multiple primary codes billed? Is the insurance company obligated to follow AMA guidelines with regard to multiple procedure reduction pertaining to the reduction of exempt codes?
  Regina S. Baldwin, NY
• What is the most appropriate way to bill the fee schedule when using a –62 modifier?
  Robert F. Holmdel, NJ
• Is it appropriate to bill an exploration of fusion when the surgeon believes that there is a pseudoarthrosis and performs a subsequent re-fusion?
  Jean H. Iron Mountain, MI

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Q2: How do you determine the CPT code order on the HCFA form?
Answer: When I code out spine surgery, I code it out in the sequence of procedures. I don’t rely on the RVU method or the highest billed code to determine the order of my CPT codes. When billing out the CPT code it is necessary to keep in mind additional levels and in addition to codes connected to the primary surgery. This will eliminate the possibility of a denial when the claim is adjudicated.

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Q3: Can an insurance company dictate policy regarding payment on multiple primary codes billed? Is the insurance company obligated to follow AMA guidelines with regard to multiple procedure reduction pertaining to the reduction of exempt codes?
Answer: Insurance companies can dictate their own medical policy guidelines. Medicare has its own policy guidelines known as the Correct Coding Initiative. The Correct Coding Initiative is actually a manipulation of the AMA guidelines and are presented quarterly.

Insurance companies have the right to dictate medical policy guidelines with regard to reimbursement, authorization, and coverage policies. Before signing a contract, it is recommended that the physician obtain a copy of the medical policy guidelines specifically addressing any manipulation of the AMA guidelines.

In short, the insurance company is not obligated to follow AMA guidelines. Insurance companies that state that they follow CCI or AMA guidelines are obligated to follow them precisely.

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Q4: What is the most appropriate way to bill the fee schedule when using a –62 modifier?
Answer: Reimbursement for any code that utilizes a –62 modifier should incorporate a total reimbursement of 125% for services rendered which should be split between the two surgeons. The calculation would incorporate the fee times 125% divided by two in order to give you a 62.5% reimbursement rate. When billing out on your HCFA form, it is suggested that you bill out at the 125% rate expecting a 50% reimbursement of the approved fee. It is not suggested that you reduce the fee charged to 62.5% as you may be penalized with an additional reduction by the insurance carrier.

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Q5: Is it appropriate to bill an exploration of fusion when the surgeon believes that there is a pseudoarthrosis and performs a subsequent re-fusion?
Answer: It is appropriate to bill for an exploration of fusion performed before a re-fusion if there is a question of pseudoarthrosis. Code 22830 is billable under the AMA guidelines along with any appropriate fusion codes depending on the location. Please know that there are some insurance carriers that do not provide reimbursement under the medical policy guidelines for exploration of fusion performed at the same site as a re-fusion. Medicare does not cover this type of service and it is suggested that you become familiar with the medical policy guidelines of any insurance plans with which you may have a contractual agreement.

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