Question

Your organization just opened a new service line: outpatient spinal fusions. The first cervical spinal fusions were done last week, and your coders have coded 10 of them. Unfortunately, several weeks and another 25 procedures later, you get a memo from the business office stating that there are denials on Medicare fusions (17 to date). The billing manager states that it is something about a status indicator “C”. She would like you to review the CPT code assignments and help determine what the problem is and how it can be resolved because the charges for these procedures exceed $35,000 per case.

After reviewing the cases, the CPT codes are assigned are correct.

2251-arthodesis cervical

*22845-anterior instrumentation

22851-use of biomechanical device (cage)

*20936-autograft of bone from same site

*denotes a status indicator of C for that CPT code

3. Brainstorm at least three possible solutions to the problem.

Answer 1

Approptiate and correct coding is necessary for reimbursement of medicare. It is the responsibility of billing staff to check the code before submitting the claim.

From the above scenario, the denial of reimbursement is by incorrect coding. Status indicator C is coming under CPT/HCPCS code system .HCPCS status indicator C is inpatient only procedure not paid under outpatient prospective payment system. It means the HCPCS not provide payment for the procedure done in out patient setting or ACS setting.

In this situation the correct coding is necessary.it resolved with separate coding for each procedure and it will be get reimbursed.

Solutions to the problem

This problem is mainly caused due to lack of awareness regarding coding system and reimbursement for inpatient and outpatient services. First provide training and education regarding correct coding and all aspects of coding system

:monitor and check the coding before submitting the claim.

:if any denial of claim correct the coding and resubmit the claim.