Coding, Billing & Collections
outpatient and ASC facilities, requires that surgeons and facilities communicate and provide relevant coding pathways for services and devices they
use in more complex spine surgeries.
Q: What are the biggest mistakes facilities make when coding and billing for spine and joint replacements that lead to
loss in revenue?
CN: Denials and reimbursement takebacks in facilities are often tied to
insufficient documentation. The new trend is for payers to deny an entire
surgery because one element of the procedure is deemed investigational or
not medically necessary. Not only does the surgeon need to document the
surgical procedure in detail, including specifics as to what devices, biologics
and technologies they use, but the documentation of the necessity of the
procedure must be complete.
A proactive approach to surgery decision and scheduling, with full review
of the case and previous documentation from other physicians, should be
an SOP for any ortho/spine practice. Facilities need to join with surgeons
and schedulers to coordinate prior authorization, review of documentation
for necessity and payer policies to avoid denials on the facility reimbursement side of the equation.
Q: Where do you see spine surgery reimbursement trends
headed in the future for the ASC?
CN: New payer business models, including pay-for-performance and evidence-based medicine have resulted in bundled payments and focus on
outcomes. Contracts between ASC facilities and key private payers can be
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sculpted to meet not only the member's medical needs but ultimately respond to new and improving technology advances. Within this more flexible business model, where contracts address reimbursements directly, there
is opportunity to grow a currently slow-to-adapt system into a functioning
medical business model. n
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