Becker's Spine Review

38 Executive Briefing: The Future of Spine Surgery Sponsored by: ADVISERS ("SHA") The Future of Spine Surgery NT T EALTHCARE … Pervasive scrutiny and shifting trends create uncertainty for inpatient spine procedures By Todd Schuck, Senior Director-Business Development, Specialty Healthcare Advisers he business of spine has become very tricky business. "For hospital CEOs back in 1990s through mid-2000s, the business of spine and rehabilitation services was much simpler," says Barry Zeman, former hospital CEO and Head of C-Level consulting services for Specialty Healthcare Advisors, the hospital and surgeon consulting division of Musculoskeletal Clinical Regulatory Advisers, LLC (MCRA). "Back then, when a highly qualified spine surgeon on our staff wanted to do a procedure we'd simply say great, go ahead, and thank you for performing your spine procedures here…" are being asked to police themselves for outlier status, with spinal fusion, it's the quality of the medical necessity documentation for the procedure itself that's under scrutiny. With inpatient implantable cardiovascular procedures like balloon angioplasty or medical stent implants, in most cases, you have clear medical necessity based on visually apparent imaging that shows the blockage. With spinal fusion procedures there is a much greater level of subjectivity. This is why Medicare has become very clear with their requirements for documenting medical necessity prior to the procedure." Just a few short years later, with significant federal legal action on the horizon, the proposed 2-Midnight rule, significantly increased reimbursement denials of payment to providers due to pre- and post-payment Medicare reviews, the burden of proof regarding medical necessity documentation for surgical spine procedures lay squarely on the hospitals' and surgeons' performing the procedures. To add to spine surgeons' and hospitals' anxiety, spinal fusion was added to the Medicare PEPPER list last year, the fall-out from which is likely to cause increased scrutiny for a much embattled, yet vitally necessary surgical procedure. Similar to knee and hip replacement procedures, patients scheduled for elective spinal fusion procedures must have well-documented attempts at various other forms of conservative care, precise capture of imaging that clearly shows the source of the pain along with an accurate diagnoses. "Spinal procedure coding, billing and medical necessity documentation is very complex business," says Neumann. She sees errors and a great deal of confusion based on phone call inquires received on the MCRA coding and reimbursement "hotline" service phone lines. In spine, not only must you do a phenomenal job of documenting the conservative approaches used prior to the surgery, you must also get the diagnosis correct, then accurately code and bill for exactly what went on during the procedure and then sufficiently recapture everything in a discharge summary. EGIC AND OPERATIONAL REVIEW/PLANNING The biggest issue today, as past, is a hospital Development & acompared to years as long that when was codedand surgeon bill Medicare for Implementation given procedure, as the bill accurately, it was paid. Today, we're not only seeing recovery audit contractors going back after previously paid claims, CMS has given their regional payers (MACs) greater pre-payment authority allowing for denial of payment after a procedure has been performed. According to Zeman, "With ICD-10 on the near term horizon and a much greater emphasis being placed on medical necessity documentation, the days of performing cases with less than adequate documentation are gone forever." Zeman adds, "The considered opinion of the surgeon backed up by recent scans, radiographs and clinical observations is no longer adequate for smooth payment." CODING ANALYSIS & COVERAGE ACCESS When SHA performs a Spinal Fusion-Medical Necessity and Coding Analysis SERVICES GN, EVALUATION & IMPLEMENTATION they expect documentation in the patients' medical charts to reflect the appropriate diagnosis and include much of the following: P • re-procedure radiologic findings or mention of the radiology report result in the medical record RAC) PREPAREDNESS & DEFENSE SERVICES conservative measures/treatment prior to surgery • ailed F "The issue is very clear. In today's more highly regulated and restrictive pay• ocumentation of duration of pain and/or impairment of function D ment environment both the hospital and the surgeon need to ensure that all • hysical exam documenting the functional pathology P of the medical necessity documentation to support and justify the procedure is there, clearly written in the patient medical record, particularly when it • ocumentation of instability if applicable D comes to elective procedures like spinal fusion and joint replacements," says Zeman. "Unfortunately, execution of complete documentation as required by StrategicpayersOperational Guidance for Healthcare Providers by: & is highly variable and often inadequate to prove necessity to their Medicare MACs and RACs finding high the bility, satisfaction."the need Sustainability, Whilerecordsprocedures Risk Exposure. Quality With both pre- and post-payment audits of spinal has never error2013, the Medicare spinal fusion DRG-460 of a and for flawlessly documented medical Reducing In April rates with MAC payer Novitas published the results on the rise, service-wide post pay probe review for DRG 460 (spinal fusion except cervibeen more important. cal without major complication/comorbidity). As stated on their website, the ALREADY BEEN EARNED…ENHANCING PROFITABILITY rate for their Jurisdiction 12 was 73 percent, with denial average dollar error Spinal surgery procedures under intensirates ranging from 50 percent to 90 percent. A similar review of spinal fusion fied scrutiny- DRG 460-added to PEPPER DRG 460 by Cahaba GBA (another MAC payer), completed in October 2012 For years Medicare watchdogs have been concerned about the increasing demonstrated an overall claim error rate of 64 percent with 88 percent of the prevalence of spinal fusion procedures amongst their beneficiaries. In March denials resulting from the lack of documentation of the appropriate indica2012, spinal fusion procedures were placed on the Medicare Program for tions for the spinal fusion. Evaluating Payment Patterns Electronic DOCUMENTATION CODING PINAL FUSION MEDICAL NECESSITY Report target list, otherwise known as the PEPPER list. Procedures on this dubiously infamous list include hosThis past October 2013, an update from Palmetto GBA, another MAC who pital admissions which have the highest propensity for improper payments. has been administering Medicare health insurance claims for CMS since the onsulting bzeman@sha-mcra.com | (516) 702 1100 Mid-90s revealed the results of their pre-payment service specific probe re"What's unique about spinal fusion procedures being added to the PEPPER view of DRG 460 in North Carolina, Virginia and West Virginia. Palmetto's list is the nature of the scrutiny," says Carolyn Neumann,(860) 904 4447 ess Develoment tschuck@sha-mcra.com | Sr. Manger Coding findings exposed extensively high error rates regarding lack of medical necesand Coverage Access for Specialty Healthcare Advisers, Manchester, Conn. sity documentation creating cause for significant concern nationwide. "Unlike most other admissions on the PEPPER target list where hospitals RE ADVISERS - MISSION:

• Cover